Image-Guided Aesthetic Treatments [1st ed. 2023] 3031362640, 9783031362644

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Image-Guided Aesthetic Treatments Robert L. Bard Editor

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Image-Guided Aesthetic Treatments

Robert L. Bard Editor

Image-Guided Aesthetic Treatments

Editor Robert L. Bard The Angio Foundation and Bard Diagnostics New York, NY, USA

ISBN 978-3-031-36264-4    ISBN 978-3-031-36266-8 (eBook) https://doi.org/10.1007/978-3-031-36266-8 © Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my wife, Loreto, whose vision allowed the creation of this international collaboration and whose steadfast guidance coalesced advanced noninvasive imaging with newer aesthetic treatments supporting breakthrough therapeutic outcomes.

Foreword

Dr. Robert Bard is one of the world’s experts in ultrasound technology. More specifically he has pioneered ultrasound imaging of the skin for malignant and benign lesions and has taken this technology from concept to an integral part of a medical practice. In the aesthetic arena there has been a major emphasis in recent years on procedural safety in fillers, fat grafting, and laser treatments. Dr. Bard has brought the masters in imaging and aesthetic treatment together to teach the rest of us how to perform safer more effective aesthetic treatments with adjunctive imaging. Image guidance allows the physician to measure the skin thickness and the depth of fat tissue as well as evaluate the elasticity of the skin and subcutaneous tissues. Medical imaging maps the arteries, veins, and nerves providing preoperative landmarks reducing postoperative bleeding and avoiding nerve damage. Intraarterial filler injection has led to irreversible blindness and skin loss. Imaging permits safer therapeutics with increased effectiveness and decreased treatment times. Image-guided treatment greatly reduces patient anxiety even by simply helping to avoid bruising and the possibility of postoperative disfigurement. Benign disease and cosmetic treatment options are further improved by 3-D volumetric mapping of regional anatomic structures. This data set allows for serial accurate comparison in follow-up exams for comparison and research studies. The ability to follow the course of nerves allows for ultrasound-guided nerve block anesthesia and decreases the possibility of nerve injury during treatment. New cryoprobes/thermi-needles target nerves of the face producing muscle relaxation similar to Botox injections without the cost and bruising sequelae. Imaging may noninvasively identify subdermal fillers or implants as to content and location. Translocation of fillers/implants may be observed and corrected by real-time interventions. The book combines the use of optical media including dermoscopy, confocal microscopy, OCT (optical coherence tomography), high-resolution 3D ultrasound, real-time 4D Doppler histogram analysis, dermal MDCT, and DCE-MRI scanning. This is the first time these modalities have been discussed in one format for aesthetic purposes. Some of this technology is currently expensive and beyond the scope of most practitioners. However, vii

Foreword

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historically these procedures become less expansive and more mainstream over time and in the future we will be referencing this publication for advances that will be used by aesthetic practitioners on a daily basis. Boca Raton, FL, USA

Jason Pozner

Contents

1 Industry  Review of the Aesthetic Industry������������������������������������   1 January E. Howard and Lennard M. Gettz 2 Facial  Danger Zones: Ultrasound Anatomy����������������������������������  11 Cameron P. Christiansen and Elie M. Ferneini 3 Intense  Pulse Light Technologies for Aesthetic Procedures and Beyond����������������������������������������������������������������������������������������������  19 Michelle P. Zappas 4 Facial  Danger Zones in Aesthetics��������������������������������������������������  29 Beth Haney and Michelle P. Zappas 5 Bard:  Aesthetics—4D Facial Nerve Biomicroscopy����������������������  39 Robert L. Bard and Paul Dreschnack 6 Facial Rejuvenation/Non-Surgical Procedures ����������������������������  51 Beth Haney 7 Dermal  Fillers for Facial Rejuvenation������������������������������������������  65 Arun K. Garg 8 Into  the World of Laser Resurfacing����������������������������������������������  97 Robert L. Bard and Cameron Rokhsar 9 Low-Level  Light Therapy with LEDs�������������������������������������������� 111 Cari Green and Gabriel Borden 10 Tips  and Tricks for Intense Pulse Light Treatment���������������������� 127 Lucian Fodor and Sergiu Samuila 11 Aesthetic  Treatments with Focused Ultrasound���������������������������� 145 Mary Nielsen 12 Nonsurgical  Esthetics for Facial Rejuvenation and Hair Restoration Using Autologous PRP and Adipose Tissue Concentrate�������������������������������������������������������������������������������������� 155 Peter A. Everts 13 Body Sculpting �������������������������������������������������������������������������������� 187 Marc J. Salzman

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14 Image-Guided Breast Oncologic Treatment���������������������������������� 213 Robert L. Bard, Noelle Cutter, and Stephen Chagares 15 Image-Guided  Superficial Radiotherapy and Other Noninvasive Modalities Used in the Treatment of Non-­melanoma Skin Cancer and Keloids�������������������������������������� 225 Lio Yu, Mairead Moloney, and Robert L. Bard 16 Aesthetic Podiatric Sonography ���������������������������������������������������� 253 Robert L. Bard and Richard Kushner 17 Holistic  Integrative Dentistry: Looking Good Versus Functioning Well������������������������������������������������������������������ 275 Robert L. Bard and Randall L. Weisel 18 Full-Arch  Implant Rehabilitation (FAIR): A Single-Visit Protocol for Restoring Function and Esthetics in Partially and Fully Edentulous Patients���������������������������������������� 295 Arun K. Garg 19 Cardiac  Ablation: Energy Sources and Delivery Platforms�������� 315 Kevin Liu and John Catanzaro

Contents

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Industry Review of the Aesthetic Industry January E. Howard and Lennard M. Gettz

Abstract

1.1 Introduction

The history of cosmetics is reviewed with technologies unfolding less invasive options and more functional solutions involving neutraceutical supplementation with natural resources. Minimally invasive options are documented as is the adaptation of therapy to the Covid-19 pandemic. This chapter dives into the positive and negative implications of aesthetic procedures and how minimally invasive tactics could help advance all procedures focusing on the sake of performance, safety, and longevity.

Conducting an industry review on the current state of the aesthetic industry would be incomplete without shedding a spotlight on social outlook and how it drives consumer activity trends. All aesthetic procedures are promoted to enhance one’s overall look and public appeal and are often theorized to elevate one’s self-appreciation. The public desire to achieve this is what supports this multi-million dollar industry to self-generate constant energy to acquire new market support each year (Fig 1.1). Historically, the study of human nature has shown consistent evidence of aesthetic personalization throughout every social class as part of natural human desire and need for visually expressing personal pride and individualism. To date, there is an ever-growing list of solutions to enhance and improve a person’s image, from PRP injections, microneedling, chemical peels, Botox, and fillers. These procedures have widely grown in popularity throughout the global community because of their affordable cost to the client/patient, their easy access, and their immediate performance and effectiveness. The future of minimally invasive modalities has projected a major market growth without any signs of slow down. Introducing aesthetic procedures to just about ANY practitioner, let it be a dentist, an OB/GYN, a plastic surgeon, or a urologist offers a natural add-on, exponentially wid-

Keywords

History · Aesthetic · Nutraceuticals · PRP · Antioxidants · Rose petals · Minimally invasive · Anti-aging · Microneedling

J. E. Howard (*) Cellular Medicine Association, Ft. Lauderdale, FL, USA L. M. Gettz Deer Park, NY, USA e-mail: [email protected]

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_1

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J. E. Howard and L. M. Gettz

or eliminating risk to the client from pain or the stress of a “land mine” event is a major selling point for imaging devices in pre and post procedures.

1.2 The Modern Age of Clinical Aesthetics

Fig. 1.1  Facial injections may avoid nerve and vascular structures under ultrasound image guidance. (© T-Photo | Shutterstock.com)

ening the access of these treatments to the community at large. Where dentists and plastic surgeons clearly have their specialized work intact, aesthetic procedures offer a supplemental income and a lucrative addition to their existing service set. For the practitioner, these procedures are a sensible upgrade by adding fairly recognizable protocols and equipment from prior training. Practitioners find the integration and learning curve of adapting aesthetic modalities into their existing practice to be quite comfortable and cost-effective. For example, one can be trained to produce their own dermal filler or bio filler by extracting PRP (which is the client’s own biologic) by “cooking” the platelet poor plasma. This is instead of purchasing bio filler from any of the existing manufacturers, offering a savings of anywhere from $300 to $800 per box. As the industry concepts of beautification evolved and expanded toward clinical procedures, a sensible upgrade is the implementation of IMAGE GUIDANCE—a valuable tool forged by medical diagnostics. For over 30 years, ultrasound imaging has offered great value in clinical applications and is now adding great directive support to injection situations whereby knowing where the veins and bones truly are could be very helpful as a matter of safety. Whether someone is new to conducting injectable treatments or is a seasoned professional, having the reassurance of visual confirmation lowers the likelihood of hitting a vein or creating an occlusion. Reducing

Throughout the twentieth century, economic and medical industry reports have traced major activity in cosmetic procedures as part of a global consumer trend of personal enhancement investments. Where elective surgical procedures like breast augmentation, liposuction, and rhinoplasty once dominated the aesthetic media, the early 1980s brought forth a new wave of Minimally Invasive procedures which forged an entire industry of cosmetic self-rejuvenation. In 1981, bovine collagen was the first agent approved by the FDA for cosmetic injection. It was developed to induce a youthful appearance (as well as address facial deformities) to target smile lines and improve the presence of facial acne scars. The first regulatory approval gave way for dozens of injectable cosmetic filling agents as well as technologies in pursuit of “antiaging” or facial enhancement. This minimally invasive treatment trend includes chemical peel, dermal fillers, laser skin resurfacing, hair removal techniques, microdermabrasion, and others [1, 2] (Fig. 1.2). We can track the history of cosmetic enhancement and aesthetic rejuvenation through the

Fig. 1.2  Optical and thermal energy devices build collagen and firm tissue characteristics. (© Vagengeym | Dreamstime.com)

1  Industry Review of the Aesthetic Industry

timeline of cosmetic body art as the earliest tribal rituals, to the old testament (840 bc) from the book of Esther to ancient Egypt (1320 bc) [3]. Since ancient times, the concept of cosmetics and facial enhancement has been part of personal essence—especially for the elite. Often, they were used in religious ceremonies—as seen in ancient Egypt—or as cultural identification [4]. Cosmetic products such as creams, lotions, and talcum powders became more globally accessible to the human zeitgeist, supporting pursuits of cultural acceptance, personal enhancement, and beauty. Tracking the aesthetic market in the west, skin care products including skin lotions, powders, creams, bleaches, ointments, and cleansers have historically accounted for a large percentage of the American cosmetics and hygiene industry. The claims and perceived notion of smoother, whiter skin is aligned with better health, and beauty has become the impression of beauty since the 1800s. Concealing and removing imperfections like freckles, rashes, and pimples are also part of the aesthetic objectives [5].

1.3 The Demand for Aesthetic Surgeries The history of plastic surgery goes back as far as between 1000 and 800 bc with Sushruta— considered the “Father of Plastic Surgery” from ancient India. He was responsible for the advancement of medicine, and his early teachings of anatomy, pathophysiology, and therapeutic strategies were achievements linked to nasal reconstruction. Sushruta’s surgical studies led to his development of the cheek flap for nasal reconstruction. His surgical concepts and his creative approaches still apply today [6]. The term PLASTIC surgery is traditionally a clinical term often used for reconstructive treatment of parts of the body affected by disease, injury, infection, birth defects, or trauma. COSMETIC or aesthetic surgery is an elective procedure that enhances or reshapes parts of the body to support the patient’s pursuit for selfesteem. Analysts identified the many influences

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of opting for cosmetic surgery—covering perceived advantages of the likelihood of a more fulfilled life. Where one’s self-confidence is linked by societal behavior with an attractive appearance through surgical enhancement, studies emphasized exposure to the media may have significant influence in pursuing cosmetic surgery [7]. One of the oldest cosmetic procedures has been Rhinoplasty (nose job) dating back to the sixth century. Within the recent decade, surgeons have perfected this process such that in 2014, Rhinoplasty has been recognized as the second most popular procedure in the USA with over 215,000 cases within a total estimate of 15M cosmetic procedures. This procedure is second in popularity only to breast enhancement. Other aesthetic procedures that fill this public demand is for gluteal implants, liposuction, and eyelid uplift [8]. The demand for enhancement procedures directly aligns with the worldwide human ambition to fight the many foibles of natural affliction of the aging process. To pursue the ability to improve one’s personal health and appearance is heavily driven by the desire to look and feel young again—such that “the battle to reverse time” has expanded this multi-million dollar market. This trend includes the increase in demand for facial aesthetics products such as anti-aging, anti-wrinkle, oxygenation, and rejuvenation neurotoxin free botulinum as well as the growing industry of minimally invasive procedures. Additionally, dental implants have been added to the list of cosmetic procedures, addressing the treatment of dental imperfections and congenital defects. More recent dermal solutions cover technology-driven laser treatments of lesions, skin toning, and the removal of tattoos, hair, and scars [8].

1.4 Risks and Complications By now, we all understand the set of risks that exist within any surgical procedure. Not only are all patients prone to different healing rates and

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capacities, but there may be a wide array of possible complications associated with cosmetic/ plastic surgeries—including infection, post-op internal bleeding, reactions to foreign materials or anesthesia, and complex issues during the healing process such as nerve damage, fluid buildup, and blood clotting [9]. 2020 news headlines published a major health alert with women who invested in textured breast implants to potentially cause breast implant-associated anaplastic large cell lymphoma (BIAALCL)—an uncommon and treatable type of large cell lymphoma that can develop around breast implants. BIA-ALCL is not a cancer of the breast tissue itself. In a 2020 FDA study, there have now been 733 unique confirmed cases worldwide which included 36 known deaths [10, 11].

1.5 Minimally Invasive/ Injectable Treatments According to international studies, the market of non-invasive aesthetic treatment has been a steady boom at an estimated USD 53B since the early 2020s with a projected growth of 15%+ for the next 10 years. This continued consumer demand for improving physical appearance in adults gained an uptick in the induction of the more affordable and more accessible non-invasive and minimally invasive aesthetic procedures within this period. INJECTABLE procedures also gained significant popularity especially in the 50+ year old age group. A high population of women are recorded to request aesthetic fillers including Botox. In 2018, an est. $2.8 billion minimally invasive cosmetic procedures were conducted domestically (according to the Grand View Research), showing a consistent rise each year of 9%—identifying its major growth in demand and popularity. These procedures rose sharply by an est 228% within 2000–2018  in the USA, and they now account for 95% of all cosmetic treatments undertaken for NSFA treatments with a 5% decrease in surgical procedures. Minimal invasiveness results in faster recovery, lesser

J. E. Howard and L. M. Gettz

Fig. 1.3  Variations on injections including microneedling procedures are useful in scar and keloid treatments. (© Karel Noppe | Dreamstime.com)

scarring, limited stress, and better patient satisfaction [5, 8, 12, 13] (Fig. 1.3). Within the last two decades, the widening term “Medical Aesthetics” has become a trend representing physical corrections and restoration beyond cosmetic applications. Injectable techniques have expanded to clinically support the aesthetic dermatologist to repair facial texture structurally through contouring, lifting, volumizing, improving muscle and tissue tone, or implement focal fat reduction. The professional may apply a host of materials into the skin including inert fillers, platelet-rich plasma (PRP), stem cells, and lipolytic agents. As the expansion of agents and injecting materials continue to grow with its demand, the inducing clinician must undergo comprehensive safety and procedural training alongside a solid understanding of the elements used in these injectable treatments in order to achieve proper outcomes [14].

1.6 The Covid-19 Pandemic and Self-Enhancement Global analytics of the aesthetics community during the coronavirus outbreak (COVID-19) in 2019 resulted in the freeze of all non-emergency/ elective hospital procedures. It is this suspension alongside the societal distress caused by the lockdown that created a backlog of procedures and an increased demand for self-enhancement. Also, other influential factors driving the rise in

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1  Industry Review of the Aesthetic Industry

Fig. 1.4 Real-time imaging may better demonstrate blood flow and thin facial nerves and provides a preop map of danger sites. (© Edward Olive | Dreamstime.com)

cosmetic surgery during the pandemic were attributed to the vast exposure to video conferencing, where more individuals are forced to view themselves (and grow critical of their appearance) during video meetings (Fig 1.4). Global studies have been implemented on adults observing behaviors and concerns while undergoing multiple video conferencing usage, including the use of video-enhancement tools to improve picture quality and focus of visual attention while on video calls. A significant percentage of participants identified appearance concerns while on video-associated with self-focused attention and increasing appearance concerns due to their time on video calls. The report concluded a large number of interest in acquiring future beauty treatments and nonsurgical aesthetic procedures such as anti-wrinkle injections. A recent colloquialism for this is the “Zoom Face Phenomenon” driven by the covid-driven boom of video conferencing (tying this issue with the Zoom video brand) [15–18].

1.7 Phasing Out the “Anti-aging” Terminology More than a definition, applying the term REJUVENATION is truly the goal vs. ANTIAGING. For decades, the term “anti-aging” has been a phrase that represented the entire marketing lexicon describing products, services, and procedures to promote aesthetic enhance-

ment. Further review of this Ageism is seen as more about stereotyping and/or discrimination against individuals or groups on the basis of their age. The science is not about recapturing the fountain of youth—alluding to a criticism of one’s natural aging process—but about firming, tightening, polishing, or skin conditioning. A commentary on social appeal dictates that beauty and attraction is defined not necessarily on looking younger but having a radiant appearance. The recent trending term identifies today’s aesthetic procedures as REGENERATIVE or AESTHETIC ENHANCEMENT, implying a more objectivebased category. Where wrinkles, shadows, and loose skin render a fatigued and worn impression, it is the million dollar industry of ENHANCEMENT that has taken on what tolls of time has done to the physical self—both the face and body [7, 19].

1.8 Overview on Minimally Invasive Procedures The value of aesthetics in our community exists throughout all social groups. The market recognizes one popular focus group in particular to include the parent community—whose exhaustive commitments to countless physical demands may oftentimes appear in their features. Investing in facial enhancements offers a sense of personal satisfaction about their renewed public appearance. In addition, such procedures have been studied to bring personal empowerment from experiencing that natural facial glow from having improved skin texture. Psychologists and counselors identify the means of having a rested appearance as looking and feeling optimized could actually support an emotional uplift by motivating the self to manifest a healthier lifestyle.

1.9 Face Lifts A facelift, technically known as a rhytidectomy (rooted from the word rhytis or “wrinkle,” and ektome “excision”—or the surgical removal of

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wrinkles), is a cosmetic process dedicated to providing a more youthful facial appearance. To achieve this, there are various surgical and minimally invasive techniques available. Surgery could mean the extraction of loose, sagging skin (often from age) and the skin tightening on the patient’s face, neck, cheeks, or eyelids. Nonsurgical enhancement strategies that address these and issues like frown lines and other facial wrinkles can also be achieved with other modern techniques such as the injection of bio fillers and the performance of laser skin resurfacing or photodynamic therapy for the removal of wrinkles, spots, and textures.

1.10 Microneedling Microneedling is a procedure using small needles to prick the skin in order to generate new collagen and healthier tissue for more toned skin. The concept of microneedling was widely used on a commercial level since the 1900s in Europe to address acne and skin scars. The technology continues in popularity throughout the aesthetics community and has evolved from manual applications to electric microneedling that may help with a wide set of issues such as fine lines and wrinkles, oversized pores, acne, dark spots, hair loss, and stretch marks [20]. As a working arsenal to dermatologists, aestheticians, and other trained clinical subscribers, microneedling is recognized to be far less costly than other skin therapeutic technologies including laser treatments, which by comparison can cost about 3–4 times. The entire process is usually around 15–20  min and may commonly require 4–6 treatments depending on need.

1.11 The PRP Process In recent years, the success of platelet-rich plasma (PRP) treatment protocols is growing in popularity, capturing an expanding share of the aesthetics market. To date, the history of the PRP therapeutic process has been recorded from Equine (Horses) Medicine since the early 1990s.

J. E. Howard and L. M. Gettz

Veterinary medicine applied the use of PRP to treat ligament damage such as tears or inflammation in the tendons. This process has also been applied in horses with osteoarthritis both showing significant success for continued research both in animals and early human studies. The evolution and success of the PRP relied on the preparation of the plasma, including volume and percentages applied and the quality and consistency of the extracted matter [21–23]. Clinical professionals find its benefits to be easily integrated within their practices to expand their services. From dentists, dermatologists, and cosmetic surgeons to most non-medical cosmetic practices, training and adopting PRP systems into a practice or aesthetic-related business has been found to require a low level of commitment and investment. The vast appeal of offering a minimally invasive (non-surgical) regenerative enhancement solution provides a great alternative to the consumer while adding a much lower cost alternative to acquiring PRP is now being used to treat chronic osteoarthritis and other orthopedic injuries and is also more widely marketed in the aesthetics channels. PRP is widely applied in various areas of the medical field for its proven properties of regenerative therapy as well as in many areas of clinical aesthetics. In dermatology, there has been significant success in PRP’s expanded use from wound healing, scar reduction, skin and tissue regeneration, and skin enhancement. The science of PRP originated in hematology IN THE 1970S as part of plasma transfusion for thrombocytopenia patients or those with low platelet count in their blood. The biological concept of plasma extraction by centrifugation of autologous blood (sourced from oneself) offers 1-to-1 cellular compatibility by accessing one’s own healing properties [24]. In aesthetics, the PRP extraction and application process forge the healing properties of the plasma—extracting the usable “platelet-rich plasma” from the “platelet poor plasma” to be used TOPICALLY in applications similar to microneedling. It is also widely applied as SUBCUTANEOUS injections such as breast lifts

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–– –– –– –– –– –– ––

Anti-inflammatory. Anti-mutagenic. Anti-oxidant. Cellular regeneration. Collagen accelerator. Internal detoxification. Dermal rehydration.

1.13 Medicinal Overview Fig. 1.5  PRP and other injectable biologics are improving blood perfusion to treated areas. (© T-Photo | Shutterstock.com)

or to increase collagen on the facial skin’s surface. PRP also offers restorative and tissue healing value for follicles in hair restoration procedures (Fig. 1.5). Under clinical supervision, PRP treatment of facial enhancement and wrinkle removal involves drawing approximately 20–60 mL of blood. The practitioner would centrifuge this to separate plasma from blood cells, capturing the injectable YELLOW matter known to be “rich in platelets.” However, in larger aesthetic services, like a vampire breast lift, or a P-shot (Priapus Shot), you actually need to draw an estimated minimum of 60  mL of blood to a rough minimum of 6–10 tubes. Upon the centrifuging process, once the PRP is harvested, in most cases, platelet poor plasma is discarded [25–27].

1.12 Historical Context of Natural Aesthetics Four thousand years ago, the Egyptians used plants especially rose petal extracts for aesthetic enhancement. The treatment of the flower of Rosa Gallica, organically grown in France, pesticide free, and chemically balanced with antioxidants, is currently used in clinical practice as an extract of whole fresh or cut and dried rose petals and rose petal tinctures: organically distilled. Traditional usage has been as follows:

Chinese medicine recommends rose petal extract for regulating vital energy or “qi,” for strengthening blood circulation, purifying the liver, and alleviating joint pains. The high concentration of anthocyanins in the petals is known for their ability to strengthen the vascular system, prevent blood platelet stickiness (blood clots), and also have powerful antioxidant, antibacterial, and anti-inflammatory activity. Rose petal essential oils were used as a dermal rehydrator to beautify the skin by the ancient Egyptians. In Roman times, people treated breast diseases, skin conditions, and even wound infections with orally ingested preparations. Research has shown that an extract from Rosa Gallica strikingly increases the effectiveness of several antibiotics against methicillin-resistant Staphylococcus aureus. Two active compounds from the extract have been identified as tellimagrandin I and rugosin B.  Other studies have demonstrated strong activity of Rosa Gallica extract against strains of Candida albicans isolated from overtreatment with antibiotics. Additionally, the effect of an anthocyanin preparation isolated from the flower petals of Rosa Gallica demonstrated strong effects of Rosa extracts against abnormal cells. A 3-year research study by the BioFoundation for Angiogenesis Research preceded the development of the chemical constituents of the ProRose+ formulation. Scientific evaluation has shown the antioxidant effect to be 10× (ten times) more powerful than green tea preparations and resveratrol formulations. Collagen regeneration has been observed clinically and documented with high resolution sonograms. Improved blood flow to hair follicles has been demonstrated with

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vascular imaging technologies. The 2011 World Anti-Aging Conference showed poor dermal penetration of creams and good tissue regeneration with internal antioxidants. A 20-year study by the AngioFoundation revealed that the curative effects appeared in other glandular sites, such as the breast, prostate, and thyroid which was presented at the international 2021 Inflammatory Skin Disease Symposium as it showed improvement in cutaneous inflammatory processes such as psoriasis, rosacea, lupus, hidradenitis, and related collagen type diseases.

1.14 Active Ingredients Rose petals contain anthocyanins and proanthocyanidins, tellimagrandin I and rugosin B; carotenoids, and plant acids including gallic acid and essential oils. The liquid portion of oil of rose contains as its chief constituent the alcohol geraniol. Geraniol, with a rose-like odor, is a primary alcohol and yields, upon oxidation, the aldehyde citral, also present in rose petals. Rose oil furthermore contains about 20% of l-citronellol. A proprietary blend of balancing antioxidants has been added to the extract. Rose petals as concentrated extract/elixir with the recommended dosage of 10–20 drops twice per day. Drug Interactions: None known Contraindications: None known except alcohol dependence. Side Effects: Allergic reactions are possible in susceptible persons. Synergism: When combined with Coenzyme Q10 and resveratrol, the treatment benefit is enhanced.

1.15 Epilogue The modern age of aesthetic procedures has much to thank the medical scientific community when it comes to their approach and strategies behind clinical treatments. Recent visionary concepts such as injectable bio-fillers are clearly rooted from the same delivery of therapeutic material, showing similar logic, tools, and applications. Also, medical innovations such as

laser, ultrasound, radiotherapies, and other noninvasive electronic devices have also added a major foothold to the aesthetics movement. The evolution in clinical aesthetics continues to advance all procedures especially for the sake of performance, safety, and longevity. Over time, this level of evolution also reflects on the economics and access of these procedures— where the major BOOM in aesthetic modalities has clearly engaged the global market. And as the global market maintains a major uptick in demand for aesthetic procedures, so continues the introduction of new protocols, strategies, and improvements in treatment options and opportunities.

References 1. Breaking down the most popular noninvasive cosmetic treatments, American Society of Plastic Surgeons, Rod Rohrich | Dallas, TX Friday, June 16, 2017. https://www.plasticsurgery.org/news/blog/ breaking-down-the-most-popularnoninvasive-cosmetic-treatments. 2. Kontis TC, Rivkin A. The history of injectable facial fillers. Facial Plast Surg. 2009;25(2):67–72. https:// pubmed.ncbi.nlm.nih.gov/19415573/. 3. History of cosmetics. https://en.wikipedia.org/wiki/ History_of_cosmetics. 4. Library of Congress. History of the beauty business. https://guides.loc.gov/business-of-beauty/history. 5. Cosmetics and personal care products in the medicine and science collections. https://americanhistory.si.edu/ collections/object-groups/health-hygiene-and-beauty/ skin-care. 6. Sushruta: father of plastic surgery. https://pubmed. ncbi.nlm.nih.gov/23788147/. 7. Colbert S.  University of Missouri. h t t p s : / / w w w. m u h e a l t h . o r g / o u r - s t o r i e s / cosmetic-vs-plastic-surgery-whats-difference. 8. Worldwide Medical Aesthetics Industry—market is expected to grow at a CAGR of 9.9% between 2021 to 2029. https://www.globenewswire.com/news-rel ease/2021/03/05/2187849/28124/en/WorldwideMedical-Aesthetics-IndustryMarket-is-Expected-toGrow-at-a-CAGR-of-9-9-Between-2021-to-2029. html. 9. Complications of reconstructive plastic surgery. Stanford Healthcare. https://stanfordhealthcare.org/ medicaltreatments/r/reconstructive-plastic-surgery/ complications.html. 10. BIA-ALCL Physician Resources. American Society of Plastic Surgeons. https://www.plasticsurgery.org/ for-medical-professionals/health-policy/bia-alcl-

1  Industry Review of the Aesthetic Industry physicianresources#:~:text=The%20August%20 2 0 % 2 C % 2 0 2 0 2 0 % 2 C % 2 0 F DA , w h i c h % 2 0 included%2036%20known%20deaths. 11. Bia-ALCL: American Society of Plastic Surgeons. https://www.plasticsurgery.org/for-medical-professionals/health-policy/biaalcl-physician-resources/ summary-and-quick-facts. 12. GVR report: non-invasive aesthetic treatment market size, share & trends report, non-invasive aesthetic treatment market size, share & trends analysis report by procedure. https://www.grandviewresearch. com/industry-analysis/non-invasive-aesthetictreatmentmarket#:~:text=According%20to%20 the%20American%20Society,the%20market%20 in%20the%20country. 13. Characteristics of patients seeking and proceeding with non-surgical facial aesthetic procedures. NIH. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7935348/. 14. Trends for facial injectable therapies in medical aesthetics. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6128160/. 15. Medical aesthetics market to reach USD 16,034.87 million, globally, by 2028 at 12.5% CAGR-  COVID-19 impact and global analysis by the insight partners. https://www.prnewswire.com/ news-releases/medical-aesthetics-market-to-reachusd-16-034-87-million-globally-by-2028-at-12-5cagr%2D%2D%2D%2Dcovid-19-impact-and-global-analysis-by-the-insight-partners-301387695.html. 16. The zoom effect: exploring the impact of video calling on appearance dissatisfaction and interest in aesthetic treatment during the COVID-19 pandemic. NIH. https://pubmed.ncbi.nlm.nih.gov/34146086/. 17. ‘Zoom face’ phenomenon has people eyeing plastic surgery—by Sandy Cohen February 3, 2022, UCLA. https://connect.uclahealth.org/2022/02/03/

9 zoom-face-phenomenon-has-people-eyeing-plasticsurgery/. 18. Commentary on: The Zoom Boom: how video calling impacts attitudes towards aesthetic surgery in the COVID-19 era. https://pubmed.ncbi.nlm.nih. gov/34232299/. 19. Toxic terminology: why we’re over “anti-aging”. https://www.intoxicatingbeauty.com/intoxicatinglifestylemagazine/why-we-are-over-anti-aging/. 20. WebMD. https://www.webmd.com/beauty/ what_is_microneedling. 21. A critical overview of the use of platelet-rich plasma in equine medicine over the last decade. https://www. frontiersin.org/articles/10.3389/fvets.2021.641818/ full. 22. What is the potential use of platelet-rich-plasma (PRP) in cancer treatment? A mini review. NIH/ PUBMED. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC7113436/. 23. CEH horse report/Prp—improving treatment of tendon & ligament injuries. https://ceh.vetmed.ucdavis. edu/sites/g/files/dgvnsk4536/files/local_resources/ pdfs/pubs-HR29-1-bkm.sec.pdf. 24. Platelet-rich plasma: where are we now and where are we going? https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3445108/. 25. Availability of platelet-rich plasma for treatment of erectile dysfunction and associated costs and efficacy: a review of current publications and Canadian data. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8195577/. 26. Principles and methods of preparation of platelet-rich plasma: a review and author’s perspective. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4338460/. 27. Healthline: “what to expect from a vampire breast lift (VBL)”. https://www.healthline.com/health/ vampire-breast-lift.

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Facial Danger Zones: Ultrasound Anatomy Cameron P. Christiansen and Elie M. Ferneini

Abstract

Keywords

Soft tissue fillers are a common cosmetic procedure to correct unwanted facial feature discrepancies. The use of these fillers has grown significantly over the last few years. When proper technique is used, facial fillers typically have a successful outcome with minor complications. However, due to the high vascularity of the head and neck, major complications can occur. With any procedure, it is crucial to know how to manage complications when they arise, but more importantly, how to reduce the risk of major complications occurring. New technology and techniques have been discovered to help aid in reducing the risk, including ultrasound for visualization of important anatomical structures and soft tissue filler after placement. This chapter explores proper technique for soft tissue filler placement in the head and neck while reviewing the various filler materials and introducing ultrasound as an aid in placement.

Soft tissue fillers · Head · Neck · Ultrasound · Facial danger zones

2.1 Introduction The use of soft tissue fillers as a nonsurgical cosmetic procedure has only continued to gain popularity. In 2020, the American Society of Plastic Surgeons reported that 3.4 million soft tissue filler procedures were performed, making it the second most common cosmetic surgery procedure in the United States. With the rise of social media, online meetings, and the desire for achieving the ideal facial contour, it can be assumed that these procedures will only continue to be in high demand. Injecting soft tissue fillers in facial regions is a safe and predictable procedure, but the clinician must be trained and take caution when performing these procedures. This chapter will explore soft tissue fillers, the proper technique for placement, complications, and new technologies using ultrasound in assisting the placement of soft tissue fillers.

C. P. Christiansen Oral and Maxillofacial Surgery, Nassau University Medical Center, East Meadow, NY, USA E. M. Ferneini (*) Beau Visage Med Spa, Cheshire, CT, USA © Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_2

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2.2 Soft Tissue Fillers Soft tissue fillers can be classified as temporary (absorbable) or permanent (nonabsorbable) [1]. Temporary fillers include those composed of hyaluronic acid (HA), collagen, HA with dextranomer beads, poly-l-lactic acid, and calcium hydroxylapatite. Permanent fillers include silicone preparations, polymethylmethacrylate (PMMA) microspheres, polyacrylamide hydrogels (PAHGs), and polyalkylimide gels [2]. The most common type of soft tissue filler placed is hyaluronic acid [3, 4]. While these soft tissue fillers have varying clinical applications and properties, the technique and principles are generally the same.

C. P. Christiansen and E. M. Ferneini

volume replacement is needed. Fillers with smaller particle sizes are used when minimal volume replacement is needed and yield smoother, more natural results. If large particle fillers are used to replace minimal volume, patients could complain of the treated areas appearing bumpy and unaesthetic.

2.4 Injection Technique

When placing soft tissue fillers, it is crucial to understand which type of material and which technique is ideal to achieve the desired patient outcome. Decisions need to be made concerning the amount of volume to be replaced and the corresponding anatomy in the area of replacement. Proper selection of syringe, nee2.3 Hyaluronic Acid (HA) dles, and cannulas should also be taken into consideration with which technique is to be HA is a complex sugar molecule that naturally used for placement. occurs in the body [2]. It attracts water molecules The placement of fillers occurs at varying and gives volume to the skin. As we age, the depths depending on which type of filler you are collagen, elastin fibers, fat, and HA found in the using. Fillers with large particles are placed in the dermis break down resulting in wrinkles. HA subdermis area. If these fillers are placed too fillers are used to correct these wrinkles by superficially, a lack of aesthetic outcome can be providing the skin with the HA needed to attract achieved. This can occur as a result of the area water to the area and replace the depleted volume. appearing bulky and bumpy, or the area can The HA gels in the fillers are produced by appear as a blue discoloration due to the Tyndall Streptococcus and cross-linked with effect. If these fillers are placed too deep, the 1,4-butanediol diglycidyl ether. The gels are then fillers are unable to adequately replace the mixed with a phosphate buffer saline solution at volume needed. Fillers with smaller sized varying concentrations [2]. The cross-linking of particles are placed more superficially just below the HA fillers is increased in comparison to the dermis. These fillers are less likely to human HA which allows the fillers to be more contribute to the Tyndall effect due to their resistant to degradation. However, these HA smaller particle size and allowing the light to molecules do breakdown over time, but clinical scatter properly. results can be expected for up to 18 months after Soft tissue injections can be made with a variinitial placement of the HA filler [2, 5]. Common ety of needles and cannulas. The gauge of the HA fillers include Restylane, Juvederm, and needle is dependent on the size of the filler Belotero. The difference between the various HA particle. If needles are to be used for placement, fillers are the particle size, the degree of cross-­ aspiration is crucial as the facial regions are linking, and the concentration of the HA gel to highly vascularized. One way to minimize the saline. Fillers with increased cross-linking and risk of injection into vasculature is by using higher concentration of HA gel result in increased blunt-tipped cannulas [2]. The initial access port longevity. The filler particle size contributes to is made through the skin using a 25  G needle the amount of volume replaced. Fillers with followed by the insertion of the cannula. These larger particle sizes are used when significant cannulas are typically longer than traditional

2  Facial Danger Zones: Ultrasound Anatomy

needles as well allowing for deeper placement and access to differing sites through the same access point, decreasing the number of initial injections. Serial injections are multiple injections made close to each other in a continuous line. It is important to ensure that there are no gaps between the injected materials, so close placement of the material is crucial to maximize esthetics [2, 6]. If minor voids are noticed after placement, the filler material can be gently massaged along the line of placement to ensure the material is unified [2, 4]. This type of injection technique is helpful in replacing minimal volume in highly esthetic areas such as the glabella, philtral column, and fine wrinkles. Linear threading is a technique in which a needle is inserted fully at the midpoint of the wrinkle in a parallel fashion. This full insertion creates a channel for the material to be deposited in. The needle is then slowly withdrawn as the clinician deposits the material in a continuous manner. This technique is useful in nasolabial folds and vermilion-cutaneous borders [2]. Cross-hatching is similar to linear threading, but the material is deposited over a larger area. Cross-hatch lines are first determined and defined. The grid should follow the appropriate contour of the injection site. The material is then deposited in a series of injections along the defined grid in the same fashion as the linear threading technique [6, 7]. This technique is used for correction of large areas, especially perioral [2]. Fanning is another technique that can be used. This technique is achieved by first inserting the needle and injecting the material. The needle is then moved to a different location in a clockwise or counter-clockwise manner without being fully withdrawn, leaving the needle tip in the skin and placing more filler [2]. Moving in this direction allows for proper contour and even distribution. Fanning also reduces the number of times a patient needs to have their skin penetrated, decreasing discomfort. This technique is used in deep nasolabial folds, marionette lines [7], and deep malar injections [2].

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2.5 Complications With any surgical and non-surgical procedure, there is always the risk of complications. Soft tissue fillers are no different, and patients should be fully informed of the possibility of complications, both minor and major. Minor and more common complications include swelling, bruising, tenderness, erythema, and itching [2]. Major complications include infection [1], hypersensitivity [2], necrosis [2, 4, 8], and blindness [4, 8]. Infection rates are estimated to be around 0.004–0.02% [1] and are most commonly associated with insufficient disinfection of the site prior to injection. It is important to use an alcohol wipe to clean the area to reduce the chance of infection. Hypersensitivity reactions are not as common due to the improved purity of the filler product. Trace proteins were more commonly found in older fillers and contributed to this complication [2]. Skin necrosis in the site of the injection is typically seen when filler is injected in large quantities around or in vasculature [2]. It has been found that the incidence in all soft tissue filler procedures resulting in tissue necrosis is 0.001% [8]. High risk areas of tissue necrosis include the glabella, nasal ala, lip, and nasolabial fold. Blindness is the most severe complication reported with soft tissue fillers. A literature review was performed in 2015, and 98 cases of vision changes were reported [9]. High risk areas included the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and the forehead (12.2%). While the risk of blindness is low, clinicians must ensure they take every precaution to avoid this life altering complication. Aspiration prior to injection is crucial to ensure that the tip of the needle is not located in an artery, allowing the retrograde travel of filler through the bloodstream to the eye [10].

2.6 Facial Danger Zones With all facial fillers, understanding the anatomy of the areas where you are injecting is crucial. Understanding this anatomy and the various dan-

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C. P. Christiansen and E. M. Ferneini

ger zones of the face is vital in decreasing the risk of complications.

2.7 Upper Face The supraorbital artery is a branch of the ophthalmic artery and exits the supraorbital notch which is located about 11 mm lateral to the medial canthus of the eye. It enters the corrugator muscle at the level of the supraorbital rim and travels in a medial-to-lateral direction. The supraorbital artery also has multiple branches: a deep and a superficial branch. The superficial branch anastomoses with supratrochlear artery and frontal branch of the superficial temporal artery. The supratrochlear artery also arises from the ophthalmic artery and exits the supratrochlear notch about 3  mm lateral to the medial canthus. The supratrochlear artery is a relatively superficial artery and is typically located 1–2  mm deep in the frontalis muscle. A pertinent and important anastomosis for injection of facial fillers is where the supraorbital and supratrochlear vessels anastomose with the angular artery in the nasal glabellar area. Injections in the glabellar area should be performed superficially and aspiration is essential. The central retinal artery supplies blood to the optic nerve and is a branch of the ophthalmic artery. This artery performs an anastomosis with the supraorbital, supratrochlear, and angular artery, and blockage of this artery can result in the feared complication of blindness. If the surgeon suspects any compromise to these vessels, ophthalmic evaluation should be considered. Patients might complain of vision changes, ocular pain, headache, nausea, vomiting, and lack of extraocular movements. Clinically, the signs of central retinal artery occlusion are a pale swollen retina and a chief complaint of inability to see out of the affected eye. A recent review identified 190 documented cases of blindness following injection of facial fillers [11], so while the risk is minimal, the complication still occurs and surgeons need to be aware (Figs. 2.1 and 2.2). The superficial temporal artery is the terminal branch of the external carotid artery. It originates

Fig. 2.1  Critical vessels of the upper and lower face

Fig. 2.2  Anatomic specimen of arteries

2  Facial Danger Zones: Ultrasound Anatomy

at the level of the mandibular ramus and extends superiorly traversing the parotid gland and running superficially to the zygomatic process and temporal bone. The artery has two branches: the parietal and frontal, which are located superficial to the frontalis muscle. With regards to facial fillers, the frontal branch of the superficial temporal artery is an important vessel to be cognizant of and it has been found to have an average diameter of 2  mm. When injecting fillers, the surgeon should place them deep in the periosteal plane or take extra care and precaution when placing the fillers more superficial.

2.8 Midface The midface is highly vascularized with all major arteries forming anastomoses with each other. For injections in this area, fillers should be placed deep to avoid vascular compromise. The dorsal nasal arteries, or external nasal arteries, arise from the ophthalmic artery, supplying the upper eyelid and lateral nose and eventually anastomosing with the angular arteries on each side of the nose. The angular artery is the terminal end of the facial artery and can be detected around 5  mm medial to the medial canthal vertical line. The lateral nasal artery is a branch of the facial artery and travels parallel to the ala of the nose toward the tip of the nose. The artery forms anastomoses with the septal branches of the superior labial artery, angular artery, ophthalmic artery, internal maxillary artery, and smaller nasal surface arteries. It also forms an anastomosis with the contralateral lateral nasal artery. These arteries perfuse the skin and cartilage of the nose, along with other deeper structures in the nose. The infraorbital artery is a branch of the maxillary artery and exits the infraorbital foramen. The infraorbital foramen is located approximately 1/3 the distance between the medial and lateral canthi. The distance inferiorly between the infraorbital rim and the infraorbital foramen is about 11 mm. The infraorbital artery is responsi-

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ble for supplying the skin of the lower eyelid and middle face. As it travels in the inferior direction after emerging from the infraorbital foramen, it is located deep to the levator labii superioris muscle and superficial to the levator anguli oris muscle. Prior to placement of facial fillers in this area, surgeons should palpate the infraorbital foramen and avoid injections medial to it toward the medial canthus. If the surgeon determines that filler should be placed medial to the infraorbital foramen, filler can be placed laterally and pushed medially to the desired location.

2.9 Lower Face The lower face is the location of the main artery of the face, the facial artery. The facial artery is a branch of the external carotid artery, traversing through the submandibular gland at the lower border of the mandible and continuing in a superior medial oblique fashion across the face. While traveling, the facial artery gives off branches including the submental, inferior labial artery, and superior labial artery. The terminal end of the facial artery becomes the angular artery, as discussed previously. The main trunk of the facial artery travels deep to the platysma, which can act as a safety barrier when injecting. The inferior labial artery is commonly located posterior to the mucosal-muscular interface and below the superior border of the lip. Injections in this area should be made superficially and no greater than 2  mm deep. The needle should be inserted at the vermillion border or within the dry vermillion. Injections of the upper lip should also be made superficially in the submucosa later in a fanning technique. The superior labial artery is largest in diameter at the labial commissure and smallest in diameter at the midline. The artery is also deepest at the branch point of the facial artery and most superficial at the peak of Cupid’s bow. Intravascular injection of filler material around the lips can lead to tissue and lip necrosis (Fig. 2.3).

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Fig. 2.3  Lower lip discoloration due to arterial insufficiency from aberrant filler placement

2.10 Ultrasound in Soft Tissue Filler Placement When placing soft tissue fillers, knowing where you are injecting is crucial. Ultrasound has been used for many years to view soft tissue and subcutaneous structures. It is an easy-to use, noninvasive modality that works as sound waves from the ultrasound transducer travel through the body. As these sound waves encounter a structure, tissue, or material, they are reflected back to the transducer at varying strengths. Materials or structures higher in density reflect stronger and produce a bright or white (hyperechogenic) signal. Low density structures reflect a gray (hypoechogenic) signal or black signal (anechoic) [12]. Ultrasound can be used to identify important anatomic structures and also examine the placement of fillers postoperatively. Prior to injecting filler material, sonography can be used to visualize the epidermis, underlying dermis, subcutaneous tissues, muscles, vessels, and other structures. The first layer visible is the epidermis, and it appears as a hyperechoic line. However, this line is not actually the epidermis and is called the epidermal echo. The epidermal echo is created by reflections of the ultrasound gel on the skin. The dermis is the next visible layer and is recognized as an area of heterogeneity with varying strengths of hyperechoic reflections of the collagen and hypoechoic reflections of the extracellular matrix between the collagen fibers.

C. P. Christiansen and E. M. Ferneini

Small vessels, hair follicles, and glands potentially can also be observed based on the type of transducer being used and the area observing. The third layer seen is the subcutaneous layer and is typically visualized as a hypoechoic area with linear hyperechoic areas. Muscles are also able to be visualized by ultrasound and appear anechoic or hypoechoic. Blood vessels appear anechoic under ultrasound and are important to recognize when using ultrasound prior to filler injection. If desiring to better identify vessels, Doppler ultrasound can be used. This type of ultrasound is used to monitor the flow of liquid in a vessel. Depending on the direction of the flow, the Doppler signal is either red or blue [13]. Hyaluronic acid fillers are able to be visualized with sonography and appear as scattered anechoic round structures localized to the area where they were deposited immediately after placement. As time passes, the fillers are resorbed and appear smaller; however, they remain localized to the same location and maintain their anechoic status. After a period of 12–18 months, the filler can become very difficult to visualize with sonography due to resorption [14, 15]. Doppler ultrasound can also be used for patients who have been injected with HA filler mixed with lidocaine to better visualize these fillers. Oftentimes you will see blood flow as indicated by the red and blue colors surrounding the filler deposits [13]. Correction of incorrect placement or reactions to fillers can also be aided with the use of ultrasound.

2.11 Conclusion Overall, the use of soft tissue fillers in the head and neck is a safe and effective procedure, when trained properly and safety is taken. These fillers will only continue to become more common and surgeons need to become proficient and skilled in their delivery. Minor side effects are common and are not typically a medical emergency, but it is crucial to know how to manage and recognize the signs of critical complications. Because the face is highly vascularized, it is crucial that

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7. Bass LS. Injectable filler techniques for facial rejuvenation, volumization, and augmentation. Facial Plast Surg Clin North Am. 2015;23(4):479–88. https://doi. org/10.1016/j.fsc.2015.07.004. 8. Ferneini EM, Ferneini AM. An overview of vascular adverse events associated with facial soft tissue fillers: recognition, prevention, and treatment. J Oral Maxillofac Surg. 2016;74(8):1630–6. https://doi. org/10.1016/j.joms.2016.03.009. 9. Beleznay K, Carruthers JDA, Humphrey S, Jones D.  Avoiding and treating blindness from fillers: a review of the world literature. Dermatol Surg. 2015;41(10):1097–117. https://doi.org/10.1097/ DSS.0000000000000486. 10. Ferneini EM, Hapelas S, Watras J, Ferneini AM, References Weyman D, Fewins J.  Surgeon’s guide to facial soft tissue filler injections: relevant anatomy and 1. Ferneini EM, Beauvais D, Aronin SI.  An overview safety considerations. J Oral Maxillofac Surg. of infections associated with soft tissue facial fill2017;75(12):2667.e1–5. https://doi.org/10.1016/j. ers: identification, prevention, and treatment. J Oral joms.2017.08.026. Maxillofac Surg. 2017;75(1):160–6. https://doi. 11. Chatrath V, Banerjee PS, Goodman GJ, Rahman org/10.1016/j.joms.2016.09.004. E.  Soft-tissue filler–associated blindness: a sys2. Ferneini E, Boynton T, Almunajed H, Dimitrov K, tematic review of case reports and case series. Plast Banki M. Review of facial fillers and injectable neuroReconstr Surg Glob Open. 2019;7(4):e2173. https:// toxins. Am J Cosmet Surg. 2013;30(2):53–60. https:// doi.org/10.1097/GOX.0000000000002173. doi.org/10.5992/AJCS-­D-­12-­00028.1. 3. Ramanadham SR, Rohrich RJ.  Newer understand- 12. Schelke LW, Van Den Elzen HJ, Erkamp PPM, Neumann HAM. Use of ultrasound to provide overall ing of specific anatomic targets in the aging face as information on facial fillers and surrounding tissue. applied to injectables: superficial and deep facial Dermatol Surg. 2010;36(Suppl 3):1843–51. https:// fat compartments—an evolving target for site-­ doi.org/10.1111/j.1524-­4725.2010.01740.x. specific facial augmentation. Plast Reconstr Surg. 2015;136(5 Suppl):49S–55S. https://doi.org/10.1097/ 13. Schelke LW, Decates TS, Velthuis PJ. Ultrasound to improve the safety of hyaluronic acid filler treatments. PRS.0000000000001730. J Cosmet Dermatol. 2018;17(6):1019–24. https://doi. 4. Rohrich RJ, Bartlett EL, Dayan E. Practical approach org/10.1111/jocd.12726. and safety of hyaluronic acid fillers. Plast Reconstr Surg Glob Open. 2019;7(6):e2172. https://doi. 14. Romana Grippaudo F, Mattei M. The utility of high-­ frequency ultrasound in dermal filler evaluation. org/10.1097/GOX.0000000000002172. Ann Plast Surg. 2011;67(5):469–73. https://doi. 5. Newman J. Review of soft tissue augmentation in the org/10.1097/SAP.0b013e318203ebf6. face. Clin Cosmet Investig Dermatol. 2009;2:141–50. 15. Micheels P, Besse S, Flynn TC, Sarazin D, Elbaz https://doi.org/10.2147/ccid.s3631. Y. Superficial dermal injection of hyaluronic acid soft 6. Vedamurthy M, Vedamurthy A.  Dermal filltissue fillers: comparative ultrasound study: fillers. ers: tips to achieve successful outcomes. J Dermatol Surg. 2012;38(7):1162–9. Cutan Aesthet Surg. 2008;1(2):64–7. https://doi. org/10.4103/0974-­2077.44161.

clinicians aspirate prior to injection and also deposit the material slowly and in control. Using tools such as ultrasound can only aid in the placement and safety of these procedures. Identifying important anatomical structures prior to placement can help decrease the risk of major unwanted complications. If patients are managed appropriately, patients can expect desired esthetic results with minor complications.

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Intense Pulse Light Technologies for Aesthetic Procedures and Beyond Michelle P. Zappas

Abstract

LASER stands for light amplification by stimulated emission of radiation. Lasers interact with the skin in different ways: via reflection, absorption, scattering, or transmission of energy. Dispersion of photons occurs when the light from the laser is absorbed by the tissue. Intense Pulse Light (IPL) technology works by transmitting the energy to the chromophores; the absorption of energy generates heat and destroys the target by thermocoagulation (Raulin et al., Lasers Surg Med. 32:78– 87, 2003). The main chromophores are hemoglobin, melanin, and water. These biomolecules are responsible for many of the pigment and vascular changes that are treated with IPL. This chapter explores the usefulness of IPL treatment regarding its non-invasive healing of many aesthetic dermatologic conditions. Keywords

Intense pulse light · Rosacea · Acne · Malignant lesions · Skin rejuvenation · Aesthetic

M. P. Zappas (*) University of Southern California, Los Angeles, CA, USA e-mail: [email protected]

3.1 Introduction to IPL Technology There are a variety of lasers usually named by the lasing medium [1]. Different lasers are used to treat different skin conditions as determined by the wavelength and energy output. For example, the carbon dioxide (CO2) and erbium:yttrium-­ aluminum garnet (Er:YAG) are often used in skin resurfacing; however, down time is often an issue [1]. IPL is often used to treat vascular and pigment changes. Table  3.1 details different examples of laser types, wavelengths, and clinical uses (adapted with permission from Haney [1]) (Fig. 3.1). The majority of IPL have settings that can be adjusted to treat specific conditions [2]. The pulse duration, energy fluence, and wavelengths are adjusted by the clinician depending on the patient’s skin type and condition to be treated. Wavelengths between 400 and 1000  nm are absorbed by chromophores [3]. The IPL device incorporates various cutoff filters; the filter cuts off the lower wavelengths, and the emitted light with the longer wavelengths is used to pass to the treated area [3]. As an example, the 560 nm filter will emit wavelengths longer than 560  nm and works to target more shallow lesions (see Fig. 3.2). Patient selection is fundamental to the IPL consultation. It ensures the efficacy and safety of treatment. The Fitzpatrick Skin Type Classification

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_3

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system was originally developed by physician Thomas Fitzpatrick in the 1970s. At first, Dr. Fitzpatrick differentiated four types to determine the tendency of an individual to burn or tan when exposed to the sun. The lower the Fitzpatrick score, the more likely the patient is to experience a burn. The classification system is as follows: skin phototype I is an individual who burns easily and does not tan at all; skin phototype II burns easily and tans with difficulty (often red haired, freckled individuals), and phototype III burns Table 3.1 Differences between laser types used in aesthetics Laser type Pulsed dye Ruby

Wavelength 577–695 694 nm

Alexandrite

755 nm

Diode Neodymium (Nd): YAG

800 nm 1064 nm, 1320 m

Erbium (Er): glass Er: YAG CO2

1540– 1550 nm 2940 nm 10,600 nm

Clinical use Vascular, pigment Pigment, hair reduction Hair reduction, pigment, tattoo removal Hair reduction Hair reduction, non-ablative skin resurfacing Non-ablative skin resurfacing Skin resurfacing Skin resurfacing, tissue cutting, coagulation, vaporization

Fig. 3.1  Example of an intense pulsed light (IPL) device

Fig. 3.2  IPL spectrum. (Reprinted with per mission from DiBernardo and Pozner [4])

Intense Pulsed Light (Broad Band Light) Alexandrite

UV

VISIBLE

400

Ex: YAG

CO2

10,600

2940

Nd: YAG

1064

Ruby

755

Dye

577-630

532

488-514

x-rays cosmic rays

190-390

Excimer

Argon

694

KTP

INFRARED 700

Microwaves TV and radio waves

3  Intense Pulse Light Technologies for Aesthetic Procedures and Beyond

moderately, shows immediate pigment darkening reactions, and tans moderately after 60 min of sun [5]. In 1988, the classification system is expanded to types V and VI [5]. In the United States, the most common Fitzpatrick types are 1–III; 48% of the population can be classified as type III, and types I and II make up 35% of the population [6]. Initially, category VI was made for patients with black skin. Patients with mixed races fit into the category range from IV to VI. This classification system is subjective in nature but can be useful in the diagnosis and management of skin conditions. IPL generally works best on patients with Fitzpatrick scores between I and III.  Individuals with higher Fitzpatrick scores tend to need longer pulse durations, higher wavelength filters, and decreased energy fluence to ensure safe conditions.

3.2 Treatment Procedure Before IPL, patients should sign a treatment and photograph consent as well as a post care instruction form. As part of the informed consent, patients should be made aware of the alternatives to treatment, including topical agents, laser resurfacing, and chemical peels. The ability for the patient to comply with sun avoidance before, after, and in between treatments and to complete the series should be discussed. Imaging can be a powerful tool in the treatment of the patient with IPL. Patients should first be cleansed of all facial cosmetics and placed in a supine position. At least three photographs should be taken, one head on and each profile. It is important to get all sides/angles of the face when treating with IPL because for many patients the dyschromia is on the cheeks or side of face. Oftentimes, the most significant photodamage is on the left cheek because of exposure to ultraviolet (UV) radiation while driving. These photographs can be used in the consultation with the patient to ensure that the clinician and patient are in agreement with regard to treatment expectations. A topical anesthetic may be used to ensure patient comfort. Once that is washed off, eye protection should be placed on the patient, the

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clinician, and everyone else in the room. A clear, cooling gel is placed on the treatment area. A test spot with one or two pulses in the treatment area should be performed, and the skin reaction should be observed. Parameters can be adjusted when necessary. Usually, three to five treatments spaced 4 weeks apart are recommended to achieve the best clinical results.

3.3 Vascular Lesions Vascular malformations can be treated with IPL.  Because of its ability to target vascular structures, IPL has been used regularly in the treatment of hemangiomas, vascular malformations, and telangiectasias. The pulse light is absorbed by hemoglobin within the blood vessels. A positive clinical endpoint that is seen immediately after the treatment is a dark blue to gray discoloration of the vascularity.

3.3.1 Port Wine Stains Port wine stains (PWS) are cutaneous vascular malformations which appear as pink, red, violaceous dermal patches [7]. Three in 1000 children are born with PWS; all racial groups and genders are equally affected [7]. Most malformations occur on the face, particularly along the trigeminal nerve and neck. PWS is associated with Sturge-Weber syndrome (SWS), KlippelTrenaunay syndrome, Cobb syndrome, and Proteus [7]. Although PWS are often benign, complications such as nodules, bleeding, granulomas, and tissue hypertrophy can occur. Treatment modalities such as cryotherapy, electrocautery, and excision can lead to unnecessary scarring and should be avoided. IPL has shown to be effective in the treatment of PWS improving the physical and psychological manifestations. A split face comparison study showed significant improvement of PWS with IPL [8]. Improvement was additionally noted in PWS resistant to treatment [9]. A larger retrospective analysis found 70% of patients achieved 70–100% reduction in PWS

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after 1 and 4 treatments [10]. Ho et al. found 90% of patients achieved 25% clearance, 50% achieved 25–50%, 40% greater than 50%, and 9% greater than 75% clearance [11].

3.3.2 Telangiectasias and Poikiloderma Telangiectasias are widened venules, approximately 0.1 to −1 mm in diameter, that form thin red or blue lines and fine web-like clusters on the skin. They may occur independently but are often associated with connective tissue disease, liver disease, rosacea, aging, varicose veins, sun exposure, and the overuse of steroid creams. Progressive disseminated telangiectasias is a rare skin condition characterized by a gradual dispersal of superficial telangiectasias progressing to widespread erythema [12]. Telangiectasias do not need to be treated but can be cosmetically distressing.

M. P. Zappas

Poikiloderma or erythrosis interfollicularis colli is a common skin in middle-aged patients caused by UV exposure [12] and cosmetics. Erythema, telangiectasias, and dyschromia usually occur on the neck and chest and are sometimes accompanied by increased sensitivity. Pulsed dye lasers are most effective, but telangiectasias are also responsive to YAG and IPL. In a large study of 1000 patients with telangiectasias, 89.7% experience 75–100% improvement [13]. In a study looking at IPL in the treatment for these vascular lesions, patients with poikiloderma received 2.8 treatments [12]. These patients showed excellent results with a 76–90% improvement in symptoms [12]. Two open-­labeled uncontrolled studies and retrospective study IPL treatment in 334 patients with poikiloderma of Civatte resulted in good to excellent reduction in vascular pigmentation in atrophic skin changes in 81–82% of patients after 3–5 sessions [14, 15] (see Fig. 3.3).

Fig. 3.3  Before and after facial vasculature treatment with IPL. (Reprinted with permission from DiBernardo and Pozner [4])

3  Intense Pulse Light Technologies for Aesthetic Procedures and Beyond

3.3.3 Rosacea Rosacea is a chronic, inflammatory disorder with cutaneous and ocular manifestations characterized by erythema, telangiectasias, papules, and pustules. Overtime, phymas and rhinophyma can develop. The pathogenesis of rosacea is not well understood and thought to be multifactorial secondary to UV radiation, reactive oxygen species, vascular hyperreactivity, neuropeptides, and exacerbation of immune response [16]. Microbes, such as H. pylori and demodex mites, also play a role [16]. Women and young adults seem to be affected by this disease; triggers include sun exposure and alcohol. Avoidance of environmental triggers is the first step in relieving symptoms. Patients with type I rosacea have erythematous macules due to dilated capillaries and inflammation on the nose and cheeks [17]. Transient flushing and erythema can progress to chronic, persistent erythema in type II. In type III, hyperplasia of the sebaceous glands on the nose results in rhinophyma [17]. Ocular rosacea occurs in more than 50% of cases, resulting in meibomian gland dysfunction (MGD) and related dryness, irritation, and conjunctivitis [17]. This can also be treated with IPL as discussed later. Topical brimonidine, topical oxymetazoline, azelaic acid, and metronidazole are modalities often used to treat mild to moderate rosacea. Systemic agents such as oral tetracyclines and oral isotretinoin can be used for moderate to severe disease. IPL also plays a role in the management of rosacea. A study conducted on 227 patients with rosacea, treated with 540 nm wavelength, resulted in significant improvement in the erythema and telangiectasias compared to control groups [18]. These patients were followed over 2 years and showed a reduction in recurrence of symptoms. Similar studies with varying patient sizes showed the same beneficial response [19–22]. Combination of IPL with radiofrequency may improve results.

3.3.4 Hemangiomas Hemangiomas are benign tumors of the endothelium mainly occurring on the face, neck, or upper chest [23]. They may be superficial, deep, or

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mixed. Hemangiomas are often not present at birth but rapidly grow within the first year of life. Many begin to resolve spontaneously after the first year, but others require intervention for cosmetic reasons. Oral propranolol is first-­line therapy for large lesions at risk of scarring or disfigurement [24]. IPL is better in small, superficial, or ulcerated lesions [24]. IPL has shown a clinical improvement with 75% to 100% clearance of hemangiomas in 61.29% of the patients [23]. Approximately 21% of patients had between 50% and 74% clearance [23]. Eighteen percent had only a slight improvement 25% to 49% in symptoms [23]. With all these treatments, there were minimal side effects and no scarring [23].

3.4 Acne Acne is the result of hyperactive sebaceous glands, follicle obstruction, follicular hyperkeratinization, and Propionibacterium acnes (P. acnes) colonization. It can manifest as with open and closed comedones as well as papules and pustules. Noninflammatory acne includes comedones and responds well to over-­ the-­counter treatments, such as salicylic acid and benzoyl peroxide. Erythematous papules, pustules, nodules, and cysts characterize inflammatory acne [25] and P. acnes colonization plays a prominent role. Although clearly not life threatening, acne can cause severe psychological distress and even suicidal ideation [26]. Mild to moderate acne is often treated with topical agents, such as retinoids, benzoyl peroxide, and antibiotics. Moderate to severe lesions often require systemic therapies such as oral isotretinoin, antibiotics, hormonal contraceptives, and spironolactone. Multiple studies have shown improvement of acne with IPL [27–30]. There is conflicting evidence as to whether inflammatory vs non inflammatory lesions respond best. Chang [27] conducted a split face, open label, prospective trial of 30 women with mild to moderate acne. IPL resulted in improvement of dyschromia and skin tone but did not improve inflammatory lesions [27]. Sami reported 90% clearance of inflammatory acne lesions with four to eight ses-

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sions of IPL [30]. IPL efficacy ranged from 34 to 88.3% improvement depending on the type of acne lesions (inflammatory vs. non-inflammatory); more commonly, it fell between 40 and 60% [2]. The results in treatment of acne are more efficacious when IPL is combined with photodynamic therapy (PDT). IPL is used as an activator of aminolevulinic acid HCl (ALA) and results in significant improvement of moderate to severe facial acne. At 12 weeks, there was a 75% to 85% improvement in the ALA-PDT group versus 50%–60% improvement in the IPL alone group [31]. More commonly efficacy ranged between 60% and 80% [2]. IPL can be considered a safe and effective option for acne vulgaris, especially in patients intolerant of or resistant to oral retinoids and antibiotics.

There are limited, small studies looking at the use of PDT for other malignant lesions. There is evidence that PDT may also be safe and effective for BCC, SCC, and AKs, as well as Bowen’s. One study examined use of MAL-PDT in patients with AKs, BCC, and Bowen’s disease [34]. After two treatments, the (ten) patients with BCC and (nine) with Bowen’s had complete resolution of their lesions [34]. In the treatment of melanoma, however, the conclusions are not as straightforward. There is potential for lasers to increase cell proliferation, and treatment of melanoma with IPL could worsen the lesion [38]. In general, any raised lesion suspected of melanoma should not be treated with IPL.

3.5 Premalignant and Malignant Lesions

IPL is the fifth most common aesthetics procedure, behind Botox, soft tissue fillers, laser skin resurfacing, and chemical peels [39]. Dyschromia and skin rejuvenation are common reasons for treatment with IPL resulting in an improvement in texture, fine lines, vascularity, and pigmentation [40–43].

Actinic keratosis (AK) are cutaneous lesions resulting from the proliferation of atypical epidermal keratinocytes. They are manifested by erythematous scaling, macules, papules, and plaques found in sun-exposed areas [32]. AKs are precancerous, early lesions on the continuum of squamous cell carcinoma (SCC) to basal cell carcinoma (BCC), and therefore, most providers treat them [32]. First-line treatment is topical fluorouracil, imiquimod, and the photosensitizing agents in PDT. PDT plays a prominent role in the treatment of precancerous and cancerous lesions. Laser-­assisted PDT increases its efficacy. IPL seems to be an effective treatment of AKs, but results are enhanced when combined with ALA- or methyl aminolevulinate (MAL)PDT.  Four studies [33–36] resulted in a 50%– 91% resolution of AKs. Avram and Goldman [33] showed that 68% of the AKs resolved after one treatment with ALA-PDT [33]. Another study from 2005 showed that 42% of AKs resolved with one treatment [37]. Follow-up and longitudinal studies are needed to confirm complete remission.

3.6 Photoaging and Skin Rejuvenation

3.6.1 Lentiginous Disorders Many patients, particularly older patients, with fair skin or those who have spent a lot of time in the sun will develop solar lentigos. Nine studies with an aggregate of 199 patients were reviewed documenting the use of IPL for the treatment of solar lentigines. All studies reported improved efficacy in treatment of solar lentigines and ephelides on the face and bodies after an average of 3 to 5 treatments [44–51]. Micro-­crusting is often seen after treatment of pigmented lesions, histological analysis of these crusts reveals they are composed of melanin [46]. The crusting and sloughing leads to less melanin in basal layer of the dermis and subsequent resolution of lentigines [46]. A high quality randomized observer blinded split face comparison study of 32 women (17 with ephelides and 15 with solar lentigines) compared IPL with

3  Intense Pulse Light Technologies for Aesthetic Procedures and Beyond

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Fig. 3.4  Before and after three IPL treatments of decollete. (Reprinted with permission from DiBernardo and Pozner [4]

another established treatment option of lentigines: quality switched alexandrite laser (QSAL) [52]. This study showed significant improvement in lentigines (see Fig. 3.4). Post-­inflammatory hyperpigmentation (PIH) occurred in eight patients with ephelides and one with lentigines on QSAL site, but not the IPL. IPL is effective and safe in patients when compared to QSAL—particularly in Asian patients due to the tendency toward PIH in this patient population [52].

3.6.2 Melasma Melasma can be a frustrating, chronic, recurring condition affecting women. It is often called the “mask of pregnancy” and leads to brown gray macules coalescing into patches on the face. An increase in melanin biosynthesis underlies all hyperpigmentation. When triggered by UV exposure, this often spontaneously resolves. The pathogenesis of melasma is more complicated. There seems to be a genetic predisposition, in addition to hormones, heat, and sun exposure. There is downregulation of the H19 gene in patients with melasma inducing tyrosinase expression resulting in increased melanin synthesis [53]. Estrogen results in an additional tyrosinase overexpression [53]. Hyper-functional melanocytes deposit excess melanin in the epidermis and dermis [54]. Melasma is challenging to treat. First-line treatment is topical bleaching agents, such as hydro-

quinone 4%, and sun protection. Other skin bleaching agents such as azelaic acid, kojic acid, and niacinamide can be used as alternative or in combination. In moderate to severe melasma, triple therapy (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) can be used. IPL also has good efficacy. Seven studies showed moderate efficacy of IPL in the treatment of refractory or recurrent melasma. Wang and colleagues conducted a randomized controlled trial (RCT) IPL showing significant improvement when compared to standard of care which is topical hydroquinone and sunscreen [55]. The group treated with IPL had a 39.8% improvement compared to 11.6% in the control group, but these results were only partially maintained at 24 weeks. Another RCT showed an improvement in IPL compared to triple combination treatment and sunscreen [56]. The IPL groups had a reduction in symptoms from 17.6% to 9.7% which was significantly superior to control group [56]. In patients who have not shown improvement in other modalities, IPL at low energy/joules may be an option.

3.7 Meibomian Gland Dysfunction More recently, IPL therapy has expanded from dermatologic conditions. As previously mentioned, patients with rosacea often have meibomian gland dysfunction (MGD). Sixteen million Americans have been diagnosed with dry

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eye disease [57]; however, many more are likely afflicted with symptoms. The meibomian glands are located in the upper and lower eyelids and secrete an oily substance, meibum, which helps lubricate the eye. MGD occurs when these glands become obstructed, resulting in tear film abnormalities [58]. Symptoms associated with this condition are dryness, grittiness, irritation, burning, watering, soreness, and eye fatigue [58]. The effect of IPL on MGD was discovered accidentally. Patients with rosacea were treated with IPL and noticed a reduction in the MGD, dry eye symptoms [58]. IPL is thought to work by causing thrombosis of the telangiectatic blood vessels in the eyelids, reducing demodex eyelid infestation and increasing the temperature of meibum [58]. This results in an augmentation of the structure of the meibomian glands and the fluid from a semi-solid to liquid state [58]. A randomized, double-masked placebo-­controlled trial notes significant improvement in MGD after three sessions [59]. IPL combined with meibomian gland expression also significantly improved dry eye symptomatology and safely and effectively treated MGD [60]. There is minimal data on this topic, but IPL may be useful in the treatment of MGD.

3.8 Safety, Risks, and Contraindications Complications of IPL are relatively rare and include hypo-, hyperpigmentation, burning, and checkerboard mottling. Hyperpigmentation is often resolved with avoidance of sun and topical regimens. Checkerboard patterns can be treated with additional treatment topical skin care and sun protection/avoidance. Burns usually occur when wrong filters, energies, or pulse durations are used. Patient selection can also play a role, high Fitzpatrick scores, and tanning, including self-tanner. Post treatment cooling with towels, burn gels, and topical antibiotics can help prevent and treat the burns. Hypopigmentation may occur after treatment, particularly after a burn. Hypopigmentation is more difficult to treat, and complete resolution may not occur.

3.9 Monitoring Treatment Progression with Images Consistent before and after photos are a critical part of any aesthetics treatment, especially IPL.  Pre-consultation, post treatment, and long-­term patient management are invaluable assets to help ensure an accurate detailed record of the patients’ treatment history. Preexisting issues that may affect treatment need to be documented and discussed with the patient. Providers struggle with reproducibility when it comes to before and after photos. Using a consistent background, lighting and position can help. Side by side before and after photos allow you and the patient to view their transformation. Images can help reassure the patient and allow them to view improvements in a clear manner.

3.10 Conclusions IPL is a useful treatment modality to treat a wide range of dermatologic conditions. It is non-­ invasive and effective in treating many aesthetic conditions. With the proper settings, pre-, and post-treatment instructions, IPL offers a high rate of patient satisfaction with few side effects or adverse events.

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3  Intense Pulse Light Technologies for Aesthetic Procedures and Beyond 6. Keiser E, Linos E, Kanzler M, Lee W, Sainani KL, Tang JY. Reliability and prevalence of digital image skin types in the United States: results from National Health and Nutrition Examination Survey 2003-2004. J Am Acad Dermatol. 2012;66(1):163–5. 7. Ortiz AE, Nelson JS.  Port-wine stain laser treatments and novel approaches. Facial Plast Surg. 2012;28:611–20. 8. Babilas P, Schreml S, Eames T, Hohenleutner U, Szeimies RM, Landthaler M.  Split-face comparison of intense pulsed light with short- and long-pulsed dye lasers for the treatment of port-wine stains. Lasers Surg Med. 2010;42:720–7. 9. Bjerring P, Christiansen K, Troilius A.  Intense pulsed light source for the treatment of dye laser resistant port-wine stains. J Cosmet Laser Ther. 2003;5:7–13. 10. Raulin C, Schroeter CA, Weiss RA, Keiner M, et al. Treatment of port-wine stains with a noncoherent pulsed light source. A retrospective study. Arch Dermatol. 1999;135:679–83. 11. Ho WS, Ying SY, Chan PC, Chan HHL, et  al. Treatment of port wine stains with intense pulsed light: a prospective study. Dermatol Surg. 2004;30:887–91. 12. Wenzel SM, Hohenleuter U, Landthaler M.  Progressive disseminated essential telangiectasia and erythrosis interfollicularis colli as examples for successful treatment with a high intensity flashlamp. Dermatology. 2008;217:286–90. https://doi-­org.libproxy1.usc.edu/10.1159/000151273. 13. Clementoni MT, Gilardino P, Muti GF, Signorini M, et al. Intense pulsed light treatment of 1,000 consecutive patients with facial vascular marks. Aesthet Plast Surg. 2006;30:226–32. 14. Rusciani A, Motta A, Fino P, Menichini G. Treatment of poikiloderma of civatte using intense pulsed light source: 7 years of experience. Dermatol Surg. 2008;34:314–9. 15. Weiss RA, Goldman MP, Weiss MA.  Treatment of poikiloderma of civatte with an intense pulsed light source. Dermatol Surg. 2000;26:823–8. 16. McAleer MA, Fitzpatrick P, Powell FC. Papulopustular rosacea: prevalence and relationship to photodamage. J Am Acad Dermatol. 2010;63:33. 17. Anzengruber F, Czernielewski J, Conrad C, et  al. Swiss S1 guideline for the treatment of rosacea. J Eur Acad Dermatol Venereol. 2017;31(11):1775–91. https://doi.org/10.1111/jdv.14349. 18. Luan X, Zhang J, Wu L, Zhou N. Improved telangiectasia and reduced recurrence rate of rosacea after treatment with 540 nm-wavelength intense pulsed light: a prospective randomized controlled trial with a 2-year follow-up. Exp Ther Med. 2020;19(6):3543. http://libproxy.usc.edu/login?url=https://www-­ proquest-­com.libproxy1.usc.edu/scholarly-­journals/ improved-­t elangiectasia-­r educed-­r ecurrence-­r ate/ docview/2399083439/se-­2?accountid=14749. 19. Schroeter CA, Haaf-von Below S, Neumann HA.  Effective treatment of rosacea using intense pulse light system. Dermatol Surg. 2005;31:1285–9.

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20. Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M.  Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. 2008;159:628–32. 21. Mark KA, Sparacio RM, Voigt A, Marenus K, Sarnoff DS. Objective and quantitative improvement of rosacea-associated erythema after intense pulsed light treatment. Dermatol Surg. 2003;29:600–4. 22. Liu J, Liu J, Ren Y, Li B, Lu S. Comparative efficacy of intense pulsed light for different erythema associated with rosacea. J Cosmet Laser Ther. 2014;16:324–7. 23. Li DN, Gold MH, Sun ZS, Tang AR, Wang HB, Sheng-Kang L.  Treatment of infantile hemangioma with optimal pulse technology. J Cosmet Laser Ther. 2010;12(3):145–50. https://doi.org/10.3109/1476417 2.2010.487908. 24. Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics. 2019;143:e20183475. 25. Lu L, Shi M, Chen Z. Efficacy of IPL therapy for the treatment of acne vulgaris: a meta-analysis. J Cosmet Dermatol. 2020;19:2596–605. 26. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study. J Investig Dermatol. 2011;131(2):363–70. 27. Chang SE, Ahn SJ, Rhee DY, Choi JH, et al. Treatment of facial acne papules and pustules in Korean patients using an intense pulsed light device equipped with a 530- to 750-nm filter. Dermatol Surg. 2007;33:676–9. 28. Kawana S, Tachihara R, Kato T, Omi T.  Effect of smooth pulsed light at 400 to 700 and 870 to 1,200 nm for acne vulgaris in Asian skin. Dermatol Surg. 2010;36:52–7. 29. Choi YS, Suh HS, Yoon MY, Min SU, et al. Intense pulsed light vs. pulsed-dye laser in the treatment of facial acne: a randomized split-face trial. J Eur Acad Dermatol Venereol. 2010;24:773–80. 30. Sami NA, Attia AT, Badawi AM.  Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol. 2008;7:627–32. 31. Mei X, Shi W, Piao Y.  Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light in Chinese acne vulgaris patients. Photodermatol Photoimmunol Photomed. 2013;29:90–6. 32. Criscione VD, Weinstock MA, Naylor MF, Luque C, Eide MJ, Bingham SF, Department of Veteran Affairs Topical Tretinoin Chemoprevention Trial Group. Actinic keratoses: natural history and risk of malignant transformation in the veterans affairs topical treinoin chemoprevention trial. Cancer. 2009;115(11):2523. 33. Avram DK, Goldman MP. Effectiveness and safety of ALA-IPL in treating actinic keratoses and photodamage. J Drugs Dermatol. 2004;3(1 Suppl):S36–9. 34. Downs AMR, Bower CB, Oliver DA, Stone CA. Methyl aminolaevulinate-photodynamic therapy for actinic keratoses, squamous cell carcinoma in

28 situ and superficial basal cell carcinoma employing a square wave intense pulsed light device for photoactivation. Br J Dermatol. 2009;161:189–90. 35. Haddad A, Santos ID, Gragnani A, Ferreira LM. The effect of increasing fluence on the treatment of actinic keratosis and photodamage by photodynamic therapy with 5-aminolevulinic acid and intense pulsed light. Photomed Laser Surg. 2011;29:427–32. 36. Kim HS, Yoo JY, Cho KH, Kwon OS, et al. Topical photodynamic therapy using intense pulsed light for treatment of actinic keratosis: clinical and histopathologic evaluation. Dermatol Surg. 2005;31:33–6; discussion 36–37. 37. Willey A, Anderson RR, Azpiazu JL, Bakus AD, Barlow RJ, Dover JS, Garden JM, Kilmer SL, Landa N, Manstein D, Ross EV Jr, Sadick N, Tanghetti EA, Yaghmai D, Zelickson BD.  Complications of laser dermatologic surgery. Lasers Surg Med. 2006;38:1–15. 38. Ash C, Town G, Whittall R, Tooze L, Phillips J. Lasers and intense pulsed light (IPL) association with cancerous lesions. Lasers Med Sci. 2017;32(8):1927–33. https://doi.org/10.1007/s10103-­017-­2310-­y. 39. American Society of Plastic Surgeons. Plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2020/plastic-­surgery-­statistics-­ full-­report-­2020.pdf. Accessed 2 Aug 2021. 40. Bitter PH.  Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg. 2000;26:835–42. 41. Kligman DE, Zhen Y.  Intense pulsed light treatment of photoaged facial skin. Dermatol Surg. 2004;30(8):1085–90. 42. Sadick NS, Weiss R, Kilmer S, et al. Photorejuvenation with intense pulsed light: results of a multicenter study. J Drugs Dermatol. 2004;3:41–9. 43. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. Dermatol Surg. 2002;28:1115–9. 44. Bjerring P, Christiansen K. Intense pulsed light source for treatment of small melanocytic nevi and solar lentigines. J Cutan Laser Ther. 2000;2:177–81. 45. Kawada A, Asai M, Kameyama H, Sangen Y, et  al. Videomicroscopic and histopathological investigation of intense pulsed light therapy for solar lentigines. J Dermatol Sci. 2002;29:91–6. 46. Kawada A, Shiraishi H, Asai M, Kameyama H, et al. Clinical improvement of solar lentigines and ephelides with an intense pulsed light source. Dermatol Surg. 2002;28:504–8. 47. Kent Remington B, Remington TK.  Treatment of facial lentigines in Peutz-Jeghers syndrome with an intense pulsed light source. Dermatol Surg. 2002;28:1079–81. 48. Kontoes PP, Vlachos SP, Marayiannis KV.  Intense pulsed light for the treatment of lentigi-

M. P. Zappas nes in LEOPARD syndrome. Br J Plast Surg. 2003;56:607–10. 49. Kawana S, Ochiai H, Tachihara R.  Objective evaluation of the effect of intense pulsed light on rosacea and solar lentigines by spectrophotometric analysis of skin color. Dermatol Surg. 2007;33:449–54. 50. Konishi N, Kawada A, Kawara S, Oiso N, et  al. Clinical effectiveness of a novel intense pulsed light source on facial pigmentary lesions. Arch Dermatol Res. 2008;300(Suppl 1):S65–7. 51. Sasaya H, Kawada A, Wada T, Hirao A, et  al. Clinical effectiveness of intense pulsed light therapy for solar lentigines of the hands. Dermatol Ther. 2011;24:584–6. 52. Wang CC, Sue YM, Yang CH, Chen CK. A comparison of Q-switched alexandrite laser and intense pulsed light for the treatment of freckles and lentigines in Asian persons: a randomized, physician-blinded, split-face comparative trial. J Am Acad Dermatol. 2006;54:804–10. 53. Kim NH, Lee CH, Lee AY. H19 RNA downregulation stimulated melanogenesis in melasma. Pigment Cell Melanoma Res. 2010;23(1):84. 54. Grimes PE, Yamada N, Bhawan J. Light microscopic, immunohistochemical, and ultrastructural alterations in patients with melasma. Am J Dermatopathol. 2005;27(2):96. 55. Wang CC, Hui CY, Sue YM, Wong WR, et  al. Intense pulsed light for the treatment of refractory melasma in Asian persons. Dermatol Surg. 2004;30:1196–200. 56. Figueiredo Souza L, Trancoso Souza S.  Singlesession intense pulsed light combined with stable fixed-dose triple combination topical therapy for the treatment of refractory melasma. Dermatol Ther. 2012;25:477–80. 57. Farrand KF, Fridman M, Stillman IO, Schaumberg DA.  Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90–8. 58. Cote S, Zhang A, Ahmadzai V, Maleken A, Li C, Oppedisano J, Nair K, Busija L, Downie LE.  Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev. 2020;(3):CD013559. https://doi. org/10.1002/14651858.CD013559. 59. Craig JP, Chen YH, Trunbull PR.  Cumulative effect of intense pulsed light (IPL) therapy for meibomian gland dysfunction (MGD) confirmed in prospective, double-masked, placebo controlled trial. Investig Ophthalmol Vis Sci. 2015;56(7):6194. 60. Rong B, Tang Y, Tu P, Liu R, Qiao J, Song W, et al. Intense pulsed light applied directly on eyelids combined with meibomian gland expression to treat meibomian gland dysfunction. Photomed Laser Surg. 2018;36(6):326–32. https://doi.org/10.1089/ pho.2017.4402.

4

Facial Danger Zones in Aesthetics Beth Haney and Michelle P. Zappas

Abstract

4.1 Introduction

Dermal fillers are an integral part of aesthetic practice, but there are serious complications that can arise during the procedure, especially if the practitioner has little experience or familiarity with innate structures of the face such as glands, nerves, arteries, and veins. Imaging devices using infrared and ultrasound can identify these structures and guide placement of the filler or assist in surgical procedures. These devices are an invaluable tool that can be used in aesthetic procedures, but on occasion, immediate correction or emergency intervention might be warranted. A benefit of using hyaluronic acid (HA) dermal fillers is they can be easily dissolved when necessary, with hyaluronidase.

Consideration of underlying facial structures, vascularity, and nerves is a crucial part of safely injecting temporary dermal fillers. Different areas are at increased risk for complications due to the underlying anatomical structures. The most severe complications of dermal fillers occur when it is inserted into or pressed against a vessel. This may result in occlusion of the vessel and subsequent ischemia, necrosis, or permanent vision loss. Blindness is a very rare yet debilitating consequence of facial fillers to the upper and lower face. This vision loss presents as ocular pain and reduced vision immediately after injection. It may be accompanied by ptosis, headache, dizziness, nausea, and an extraocular muscle palsy. Intravascular injection can be avoided with understanding of facial anatomy and proper injection technique. On the face, four main vessels arise from the trunk of the facial artery: the inferior labial artery, superior labial artery, lateral nasal branch (to the nasalis), and the angular artery (Fig. 4.1) [1–3]. These vessels, along with the infraorbital artery, are crucial to avoid during aesthetic procedures because they feed vital structures of the eye, nose, and lips. Occlusion of these vessels can lead to skin necrosis, scarring, blindness, and potentially, in the remote chance, cerebral infarction [4]. Areas at risk of complications include

Keywords

Injectable facial fillers · Hyaluronic acid · Hyaluronidase · Silicone · MRI · PET-CT · Granuloma · Facial vessels · Ultrasound · Poly-l-lactic acid · Calcium hydroxyapatite

B. Haney · M. P. Zappas (*) Department of Nursing, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_4

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Superficial temporal artery Posterior auricular artery Occipital artery Internal carotid artery External carotid artery

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Supraorbital artery Supratrochlear artery Angular artery Lateral nasal artery Transverse facial artery Superior and inferior labial arteries Maxillary artery Mental artery Facial artery

Fig. 4.1  Facial arteries pertinent to facial aesthetic procedures. (Adapted from Ferneini et al. 2021 [3])

virtually any area in the face that is treated with dermal fillers. During aesthetic procedures, it is essential the facial arteries be avoided to prevent upstream effects related to blood supply. Portable, handheld infrared and/or ultrasound imaging devices can locate facial arteries and other important vessels of the face and are an option for potential prevention of complications. Due to the wide variability in anatomy between individuals, imaging techniques can help deliver temporary dermal fillers in a safe manner. For example, duplex ultrasound has been used to identify single vessels when injecting in the glabellar, temporal, and nasolabial folds [5, 6]. This non-invasive technique can aid in the visualization and locate the depth of small facial arteries. The complex three-dimensional and variable structure of the vascular network in the face can be imaged with an MRI with a time of light three-dimensional camera. This technique allows for visualization of the facial arteries for safe injections in a contrast and radiation free manner [7]. The available technologies and appropriate imaging techniques are options that

can be utilized prior to a procedure to help alleviate potential emergent situations.

4.2 Danger Zones of the Upper Face 4.2.1 Infraorbital Hollows When injecting the infraorbital region, the major anatomical areas the injector should avoid are the trochlear vessels proximal to the nose and the infraorbital artery. The main branches of the infraorbital artery are the zygomaticofacial and nasal branches. The danger zone for injecting temporary dermal fillers to this area is medial to the pupil and lateral to the nasal wall (Fig. 4.2). Best practices are retromuscular, preorbital fat injections. The lateral third of the zygomatic bone is also a danger zone. Retrograde embolization of filler into the internal carotid can lead to blindness and cerebral infarction (Fig.  4.2). In order to avoid this vasculature, small amounts of filler injected deep into the suborbicularis plane or at the supra-

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ciliary arteries [9]. These arteries originate from the internal carotid artery and branches to the ophthalmic artery which supplies blood, nutrients, and oxygen to the orbit of the eyes, musculature, and eyelids. Tissue necrosis, loss of vision, and even cerebral infarction can occur if these vessels become occluded.

4.2.2 Glabella and Forehead

Fig. 4.2  Illustration of danger zones in the infraorbital area: marked area 1 shows involvement of the zygomatic malar branch with risk of skin necrosis through skin perforators, marked area 2 represents risk of arterial embolization into the internal carotid system through retrograde flow into the dorsal nasal or superficial temporal artery, before reaching the ophthalmic, retinal artery, or even cerebral arteries. (Printed with permission from Hufschmidt et al. 2018)

periosteal level with a serial puncture technique is often used [8]. Small boluses of 0.2  cc are injected and then physically pressed down. No more than 1 cc under each eye should be used in one visit in order to avoid occlusion or compression of the vascular supply. The patient can follow-up in 2 to 4 weeks for a touch-up if the desired cosmetic result is not reached with the initial dosing of the product. The orbital vascular anatomy is multifaceted and highly variable. The ophthalmic artery branches into the lacrimal artery, supraorbital artery, supratrochlear artery, the anterior and posterior ethmoid artery, and nasal artery. The musculature and globe of the eye are supplied by the long ciliary artery, short ciliary artery, anterior artery, central retinal artery, and muscular artery. The blood to the retina is distributed by the central retinal artery and the short posterior

Caution should be used when injecting temporary facial fillers into the glabella and forehead as there is a risk for vessel puncture while traversing the supraorbital or supratrochlear artery with the needle [8]. These small vessels are at risk because they lack an additional blood supply. Skin necrosis is a possible complication as the result of vascular compromise to the area (Figs. 4.3, 4.4, 4.5, and 4.6). Vision loss can also occur. The risk is greater when deep injection of filler is used to augment the profile of the glabellar region and could result in an injection of filler into the ophthalmic artery or its branches [8]. In a study investigating the glabellar and central forehead, vasculature of cadavers and ultrasound examination of healthy volunteers showed that at the glabellar point, the horizontal distance from the midline to the central artery was 4.7 and 7.8 mm to the paracentral artery and 14.7 and 19.2 mm to the superficial and deep branches of the supra-

Fig. 4.3  Note the slight discoloration of the right side during the procedure. Pt was treated with 20  units of hyaluronidase and massage to the area. Pt was instructed to use warm packs 5 times a day, take 325 mg aspirin daily (no pre-existing conditions), and return to the clinic every day for follow-up. (Photo courtesy B. Haney, DNP, FNP-­ C, FAANP, FAAN)

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Fig. 4.4  Three days post-treatment of 20  units of hyaluronidase. (Photo courtesy B.  Haney, DNP, FNP-C, FAANP, FAAN)

Fig. 4.5  Ten days after hyaluronidase treatment, daily follow-up, and home care by patient. (Photo courtesy B. Haney, DNP, FNP-C, FAANP, FAAN)

Fig. 4.6  One month after hyaluronidase treatment. After full recovery, the patient returned to the clinic 3 months later for a small amount of HA filler to the same area without any adverse events. (Photo courtesy B.  Haney, DNP, FNP-C, FAANP, FAAN)

trochlear artery [10]. From the dermis to the arteries, the depth was between 3.1 and 5.9 mm for the central artery and deep branch of the supratrochlear artery, respectively [10]. Placement of filler subcutaneously or intradermal

of the frontalis carries minimal risk of nerve damage since the supraorbital and supratrochlear nerves run in a deeper plane with the vessels running parallel to them [8]. Thus, a superficial, retrograde serial puncture technique is preferred to restore volume to the glabellar rhytids—commonly called the “elevens.” The forehead often has a convex profile appearance with a depression in the suprabrow area that can increase with age. This concavity occurs between the tuber-frontale and the supraciliary arches. The supraorbital nerve exits the supraorbital foramen via the supraorbital notch along the orbital rim and runs parallel to the supraorbital artery. This can be palpated and should be avoided by injecting laterally and 1 cm from the supraorbital foramen since a compression injury to the nerve could result. This injury can be avoided by injecting in a retrograde fashion and laterally at least 1  cm from the supraorbital foramen. Filler should be positioned deep in the supra-periosteal plane for patient safety [8].

4.2.3 Temples Anatomically, the different layers of the temporal region range from superficial to deep and are the dermis, subcutaneous fat, superficial and deep temporal fascia, and temporal muscle [8]. Vessels run in different planes of these layers. As we age, the temporal region can lose its subcutaneous fat and become convex in appearance. This volume loss results in increased visibility of the temporal crest and lateral orbital rim and the upper zygomatic arch which can be corrected with dermal fillers. There is a higher rate of visual complications with injections here related to the close proximity to the orbit and vascular connections to the carotid artery [11]. The superficial temporal artery and the frontal branch of the cranial nerve (CN) VII nerve are the two major structures to be avoided when injecting the temples. The arrangement of the artery and nerve bundle is located within the superficial temporal fascia, a continuance of the galea aponeurotica scalp [8].

4  Facial Danger Zones in Aesthetics

The temporal artery originates from the external carotid artery and branches near the parotid gland into the superficial temporal artery and maxillary artery. The superficial temporal artery’s pulse can be felt above the zygomatic arch and in front of the tragus. It can be helpful to put your nondominant finger on this pulse while injecting the temples to ensure you are avoiding this area while depositing filler to this area. The supraorbital and supratrochlear arteries also supply this region, so filler in the ophthalmic artery can lead to a retinal artery occlusion resulting in vision loss [9]. The frontal branch of CN VII innervates the muscle of the forehead and brows. It is located deep in the superficial temporal fascia and is important to prevent brow ptosis [8]. The best way to locate this danger zone is to draw a line from the earlobe to lateral brow and the tragus to the highest forehead rhytid (Fig.  4.7) [8]. That area coincides with the course of the frontal branch. A safe injection technique for this area positions product in the supra-periosteal plane that is the one up-one over technique. This access is 1  cm up from lateral supra-orbital tubercle and 1 cm over from the temporal crest (Fig. 4.8). The

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Fig. 4.8  One up one over location for safe injection of temples. (Photo courtesy of Michelle Zappas, DNP, FNP-BC)

needle should be inserted perpendicularly to the skin surface until contact with the bone is made, aspiration should be performed, and then product slowly injected in a large bolus. The recommended amount is approximately 1.00 cc in each temple but can vary depending on the anatomy of the patient [11].

4.2.4 Vessels of the Lower Face

Fig. 4.7  Danger zone when injecting temples. (Photo courtesy of Michelle Zappas, DNP, FNP-BC)

When performing aesthetic procedures, the importance of understanding facial anatomy cannot be overemphasized. Structures in facial compartments vary in distribution, and location and the type of dermal filler used can have different ramifications depending on the involvement of those structures. The temporary and absorbable dermal filler class includes HA, calcium hydroxyapatite (CaHA), collagen, autologous fat, and poly-l-lactic acid (PLLA). The permanent filler class includes liquid silicone and polymethylmethacrylate (PMMA). All dermal fillers have the potential for complications including infec-

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tion, skin necrosis, and vessel occlusion [12–17]. Aesthetic practice often is sought to refresh the patient’s appearance through replacing lost facial volume during the aging process. Changes in the tissues of the jawline, lips, cheeks, temples, and infraorbital area cause many people to worry about their appearance and explore options such as laser and dermal filler procedures, neurotoxin, and surgical procedures. Specifically, the infraorbital hollows are a bothersome feature of aging, and many patients complain of looking tired when the fat redistribution in this area changes over time. Hence, re-volumization of the under eye and other areas of the face is sought after aesthetic treatments, and most have been performed successfully with dermal filler products. However, treating any facial area with dermal fillers carries risk, and the severity of complications and the locations of pertinent vessels are crucial for the practitioner to understand. Vessels of the face include those that communicate with the brain, eyes, and muscles of mastication and expression [18, 19]. Caution when augmenting the cheeks, midface, and lateral face with dermal filler must be exercised to avoid the maxillary artery, transverse facial artery, and the facial artery (Fig. 4.1). The facial artery is significant because of its function and multiple branches that feed muscles of the face, including the buccinator, levator anguli oris, levator veli palatini, masseter, mentalis, mylohyoid, nasalis, palatoglossus, palatopharyngeus, platysma, procerus, risorius, styloglossus, and the transverse portion of the nasalis [20]. There are diverging channels between the angular branch of the facial artery and the medial branches of the infraorbital artery on the external carotid side and the dorsal nasal and supratrochlear branches of the ophthalmic artery on the internal carotid side [1]. However, like other vessels throughout the body, the facial artery can have anatomical variations. It may arise as a single vessel from the linguofacial trunk or a thyro-linguofacial trunk [21]. Accordingly, the facial artery may also arise from either the internal carotid artery or common

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carotid artery if there is no external carotid artery present.

4.2.5 Importance of Imaging in Aesthetics Facial fillers are common incidental findings on magnetic resonance imaging (MRI) and positron emission tomography–computed tomography (PET-CT) scans, and they have a characteristic appearance and typical anatomic distribution [22]. Although facial filler injections are considered safe, they are associated with several complications such as vascular compromise, blindness, and skin necrosis in severe cases. Because the deposits of filler products might mask malignancy, knowledge of typical imaging features is mandatory and MRI can be a problem-­ solving tool for unclear cases [22]. According to some experts, the images of different fillers created by MRI have specific features; for example, calcium hydroxylapatite (CaHA) has characteristic calcifications, whereas other injectable fillers have overlapping visual features [22]. The rapidly absorbing fillers, HA and collagen, and the slowly absorbing filler, polyalkylimide and polyacrylamide hydrogels (PAAG), have signal patterns compatible with high water content and have a similar appearance because of the water content. On PET-CT and PET-MRI, most fillers show physiologic high F18-fluorodeoxyglucose (FDG) uptake and are increasingly used to detect inflammation and infection, and it is also used to evaluate fever of unknown origin [22]. These filler characteristics should not be confused with pathology because abscesses, cellulitis, non-inflammatory nodules, and foreign body granulomas are common filler-related complications [16, 17, 23]. FDG should not be used when evaluating filler complications, and astute observation by the practitioner of the patient response is essential to prompt evaluation if necessary. Diagnostic imaging can help clarify the differential diagnosis in emergency cases where a patient

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notices signs of infection, loss of function, or a change in their facial structure absent or posts a recent procedure. Imaging in cases with suspected deep spread of infection, MRI or contrastenhanced CT in the emergency setting is essential [22].

4.3 Hyaluronidase Use Hyaluronidase (HYAL) is an enzyme that catalyzes hyaluronidase fillers and is used to correct occasional lumpiness of treatment, but most importantly, HYAL can prevent skin necrosis and permanent scarring from vascular occlusion due to misplaced HA filler. HYAL dissolves the HA product usually within minutes after injection of the enzyme and does not have to be injected directly into the occluded vessel, and through diffusion it can reinstate vessel circulation quickly [24]. For these reasons, many practitioners choose to use HA dermal filler products. Certain circumstances in aesthetics, for example, mis-placed filler, vascular compromise, lumpiness, or unexpected outcomes, may require the use of hyaluronidase [17, 25]. Although hyaluronidase is an enzyme that dissolves hyaluronic acid dermal filler, interestingly, it preserves endogenous hyaluronic acid. Even when large doses of hyaluronidase are used, the endogenous hyaluronidase returns to baseline after 48 h [26]. This suggests there is little reason to avoid its use when necessary, even in cases where some time has passed. Careful and constant observation of the patient’s skin response during injections of any type of dermal filler is crucial to enable the practitioner to act quickly in the event of a vascular incident. One important consideration is many of the modern dermal fillers contain an anesthetic agent (lidocaine), and this might mask the symptom of pain when a vessel is accidentally occluded. Accordingly, the signs of impending vascular compromise should be recognized by any novice or expert aesthetic practitioner (Figs. 4.9, 4.10, and 4.11).

Fig. 4.9  Day of treatment with HA filler into the nasolabial area. Note the bluish discoloration resembling a bruise. (Photo courtesy B. Haney, DNP, FNP-C, FAANP, FAAN)

Fig. 4.10  Twenty-four hours after hyaluronidase treatment. Patient was injected with hyaluronidase 100  units diluted with saline 10:1, and the area was massaged until capillary refill of 2  s was observed. Patient home care instructions included daily 325 mg aspirin, warm packs to the area 5 times a day, and daily follow-up. (Photo courtesy B. Haney, DNP, FNP-C, FAANP, FAAN)

Fig. 4.11  Nine  days after hyaluronidase treatment and home care. Complete resolution occurred in 14 days and patient returned 1  month later for subsequent HA filler treatment with excellent results and no adverse reaction. (Photo courtesy B. Haney, DNP, FNP-C, FAANP, FAAN)

The table summarizes the signs, symptoms, and skin changes of vascular occlusion from dermal fillers (Table 4.1)

B. Haney and M. P. Zappas

36 Table 4.1  Signs and symptoms of a vascular occlusion during dermal filler injections Timing, signs, and symptoms Details and clinical aspects Pain (during the Important to note is pain may be procedure) absent initially if anesthetics are used; therefore, the absence of pain would be a variable indicator of ischemia. Intensifying pain is felt in areas affected by ischemia, and the patient may then report pain. A common attribute is the pain can be more intense than expected Pallor or Blanching or skin color change blanching can occur immediately after (immediate, arterial compromise as a lasting tens of temporary phase. This can be seconds) caused from intra-arterial occlusion or pressure from filler that compresses the vessel. Important to note is if epinephrine was used, there may be temporary skin discoloration in the area Livedo phase The area of occlusion takes on a (within minutes, blotchy, reddish, or bluish occasionally appearance, oftentimes resembling within hours) a bruise. It is important to consider the patient response, assess the area closely, and look for a “lacy” aspect to determine the cause of the discoloration. Checking for a slow capillary refill (>2 s) may assist in determining arterial insufficiency Significant skin With occlusion, the skin appears discoloration dark blue or gray due to oxygen (dark blue or depletion. Important to consider grayish, occurs bruising also takes on this in minutes to appearance, and careful hours) assessment of the patient is crucial Sloughing (days This is a late sign. In an area that to weeks) has progressed to necrosis, redness and ulceration develops and this often leads to a permanent scar

4.4 Conclusion Practice pearls to avoid complications in the danger zones of dermal fillers include in-depth knowledge of facial anatomy, aspirating before injecting dermal filler product, and injecting slowly in a retrograde fashion. Tenting, or gently lifting and pinching, the skin allows more space between superficial branches of the prominent

arteries. Using a small gauge needle and a reversible agent—such as hyaluronic acid (HA) fillers—can help prevent complications since they can be quickly degraded by hyaluronidase (HYAL). Occluding the vessels using pressure or palpating important vessels might help prevent complications. It is imperative that practitioners maintain vigilance when injecting dermal fillers into the facial compartments and be aware of signs of impending vascular compromise. The use of available imaging devices and techniques that identify facial vasculature before and during procedures can increase the level of patient safety and be valuable tools to the aesthetic practitioner.

References 1. Fisher CM.  Facial pulses in internal carotid artery occlusion. Neurology. 1970;20(5):476–8. 2. Lee HJ, Won SY, Jehoon O, Hu KS, Mun SY, Yang HM, et al. The facial artery: a comprehensive anatomical review. Clin Anat. 2018;31(1):99–108. 3. Ferneini EM, Goupil MT, McNulty MA, Niekrash CE.  Applied head and neck anatomy for the facial cosmetic surgeon. Berlin: Springer International; 2021. 4. Hufschmidt K, Bronsard N, Foissac R, Baque P, Balaguer T, Chignon-Sicard B, et al. The infraorbital artery: clinical relevance in esthetic medicine and identification of danger zones of the midface. J Plast Reconstr Aesthet Surg. 2019;72(1):131–6. 5. Kadouch J, Schelke LW, Swift A.  Ultrasound to improve the safety and efficacy of lipofilling of the temples. Aesthet Surg J. 2021;41(5):603–12. 6. Lee W, Moon HJ, Kim JS, Yang EJ.  Safe glabellar wrinkle correction with soft tissue filler using Doppler ultrasound. Aesthet Surg J. 2021;41(9):1081–9. 7. Mespreuve M, Waked K, Hendrickx B. Visualization techniques of the facial arteries. J Cosmet Dermatol. 2021;20(2):386–90. 8. Carruthers A, Carruthers J, Dover JS, Alam M. Soft tissue augmentation. 4th ed. Amsterdam: Elsevier; 2018. 9. Li X, Du L, Lu JJ. A novel hypothesis of visual loss secondary to cosmetic facial filler injection. Ann Plast Surg. 2015;75(3):258–60. 10. Phumyoo T, Jiirasutat N, Jitaree B, Rungsawang C, Uruwan S, Tansatit T. Anatomical and ultrasonography-based investigation to localize the arteries on the central forehead region during the glabellar augmentation procedure. Clin Anat. 2020;33(3):370–82. 11. Cotofana S, Gaete A, Hernandez CA, Casabona G, Bay S, Pavicic T, et  al. The six different injection techniques for the temple relevant for soft tissue filler

4  Facial Danger Zones in Aesthetics augmentation procedures—clinical anatomy and danger zones. J Cosmet Dermatol. 2020;19(7):1570–9. 12. Allergan. Juvederm XC product insert; 2016. 13. Galderma. Restylane lyft with lidocaine package insert; 2018. 14. Galderma. Sculptra aesthetic prescribing information; 2016. 15. Aesthetics M. Radiesse lidocaine injectable implant. Raleigh: Merz North America Inc.; 2016. 16. Grunebaum LF, Funt D. complications of cosmetic fillers. Aesthet Dermatol. 2018;4:128–40. 17. DeLorenzi C. Complications of injectable fillers, part I. Aesthet Surg J. 2013;33(4):561–75. 18. Vigliante CE. Anatomy and functions of the muscles of facial expression. Oral Maxillofac Surg Clin North Am. 2005;17(1):1–15. v. 19. Seeley RR, Tate P, Stephens TD. Anatomy & physiology. 8th ed. Dubuque, IA: McGraw-Hill; 2008. xxi, 1116 p. 20. Meegalla N, Sood G, Nessel TA, Downs BW. Anatomy, head and neck, facial arteries. Treasure Island, FL: StatPearls; 2021.

37 21. Mangalgiri A, Namdev LN, Mahore D, Kapre M. The study of higher origin of facial artery and its surgical significance. Indian J Otolaryngol Head Neck Surg. 2015;67(1):72–4. 22. Mundada P, Kohler R, Boudabbous S, Toutous Trellu L, Platon A, Becker M.  Injectable facial fillers: imaging features, complications, and diagnostic pitfalls at MRI and PET CT.  Insights Imaging. 2017;8(6):557–72. 23. Cohen JL.  Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008;34(Suppl 1):S92–9. 24. DeLorenzi C.  Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014;34(4):584–600. 25. Carruthers J, Carruthers A.  In: Dover J, editor. Soft tissue augmentation. 3rd ed. Amsterdam: Elsevier; 2017. 26. Casabona G, Marchese PB, Montes JR, Hornfeldt CS.  Durability, behavior, and tolerability of 5 hyaluronidase products. Dermatol Surg. 2018;44(Suppl 1):S42–50.

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Bard: Aesthetics—4D Facial Nerve Biomicroscopy Robert L. Bard and Paul Dreschnack

Abstract

5.1 Introduction

Avoiding nerve injury is critical with new image-guided treatment procedures. Vascular structures are readily discernible with high-­ resolution Doppler sonography, but the facial nerves are millimeter or submillimeter in size and better imaged with real-time facial motion techniques and 4D mapping with coordinated skin targeting. This chapter explores the innovative benefits of using 4D mapping with regard to differentiating functionalization of the nerve, fascia, muscle, as well as ligaments and tendons.

2020 arrived with laser technology breakthroughs such as noncontact laser generation of ultrasound images and image-guided reflective confocal/ optical coherence laser treatment of nonaggressive skin cancers as well as new treatment protocols. This ushers in the possibility of other therapeutic options such as photon particle intervention targeted by remote laser ultrasound robotics. Treatment options include 1064 laser for minimally invasive tumors or photon irradiation on deeper or highly aggressive cancers. HIFU insonation has been successfully used for 20 years and could supplement other modalities. Near infrared radiation is being intensively investigated. 3D imaging technologies offer one-step image-guided treatment since the size, depth, margins, and tumor aggression parameters are quantifiably displayed. Real-time 3D Doppler treatment verification is critical since aggressive basal cell cancer types (morpheaform) have a 27.7% 5 year recurrence rate suggesting that earlier imaging either missed deep tumor nests or subcutaneous locoregional metastases. Ultrasound biomicroscopy plays a key role since biopsies may miss the most aggressive region thereby underestimating the potential for recurrence. 3D vessel density histogram confirms complete tumor destruction by verification of functional vascular obliteration. 4D is real-

Keywords

Skin cancers · Vascular structures · Sonography · Doppler · Autoimmune disease · Treatment

R. L. Bard (*) The Angio Foundation and Bard Diagnostics, New York, NY, USA e-mail: [email protected] P. Dreschnack Department of Surgery, St. Joseph’s Hospital, Yonkers, NY, USA

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_5

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time 3D imaging highlighting the differential motility of nerve, fascia, muscle, ligament, and tendons.

5.2 Identifying Skin Cancers Basal cell cancers (BCC) are the most common malignancy worldwide. BCCs are rarely fatal; however, certain aggressive squamous cell cancer (SCC) types have devastating health consequences via locoregional growth and circulatory dissemination [1]. Metastatic potential of BCC is determined by functional analysis of specific intratumor sonographic findings. Malignant melanoma is the leading cause of death of women in the 25–45 age range and has a 98% diagnostic accuracy using ultrasound 15–24  MHz systems and higher with 30, 48, and 70 MHz frequencies now available. More importantly, there are specific tumor vessel density criteria identifying which melanoma cancer is most aggressive using quantitative Doppler 3D histogram analysis technologies [2].

5.3 Quantifiable Digital Scanning Versus Biopsy The optical dermatologic modalities of RCM (reflectance confocal microscopy) and OCT (optical coherence tomography) are highly accurate in ruling out malignant disorders and often flag a biopsy on a visually innocent appearing lesion such as amelanotic melanoma or pigmented basal cell cancer. 4D ultrasound imaging is a real-time evaluation of a 3D volume so we know immediately the depth and quickly assess the probability of recurrence. Specific echoes generated by nests of keratin are strong indicators of aggression and analyzed volumetrically. Highly suspect areas are then

R. L. Bard and P. Dreschnack

checked for locoregional spread, and search is performed for draining sentinal node lymphadenopathy so we show our patient that the disease is completely sonographically imaged in real time as the exam proceeds in systematic diagnostic stages. 4D permits image-guided biopsy of the most virulent area of the dermal tumor and allows the pathologist to focus on the most suspicious region of the postoperative lymph node specimen mass excised from the axilla, neck, or groin. In serious cases, the patient is forewarned that the surgical operation may be complex involving skin grafts and advanced tissue reconstruction and can make advanced plans prior to definitive treatment.

5.3.1 Digital Imaging Reduces Complications Fear of complications deters patients from seeking medical advice and possible disfiguring surgical intervention so many opt for noninvasive options. One out of 33,000  moles is malignant meaning high-resolution imaging reduces unnecessary biopsies. Cancer treatment depends on accurate determination of tumor depth and penetration possibly involving facial nerves, periocular muscles, nasal bone, or ear cartilage. Verified superficial tumors may be treated topically or by low-dose non-scarring radiation therapies. Many cancers provoke a benign local immune response or concomitant inflammatory reaction that simulates a larger tumor burden. There is often cicatrix formation accompanying the body’s healing response, and benign disorders may coexist and appear clinically inseparable from the malignant lesion. Precision 4D imaging highlights the true surgical borders of the cancerous tissue resulting in smaller excisional margins, healthy tissue sparing, and reduced scar formation.

5  Bard: Aesthetics—4D Facial Nerve Biomicroscopy

5.4 Doppler Applications Blood vessel mapping using the various Doppler flow modalities is routinely used in both cancer treatment and reconstructive preoperative planning. In cancer surgery, it is important to identify aberrant large veins or significant arteries in the operative site so that hemostasis is maintained and postoperative blood loss is minimized. Before initiating cosmetic procedures or aesthetic treatments, many plastic surgeons routinely perform a screening overview scan of the facial tissues including the eye, nose, jaw, and neck to check for forgotten fillers or post procedure complications such as subdermal scar formation, intradermal calcific deposits from healed previous injuries or retained silicone, and other fillers that may have been injected in the past. Particular attention is focused on the nasal

Fig. 5.1  Nerve depicted as echogenic tubular structure

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glabellar area because instances of total, permanent blindness have been occurring for over 10 years due to the inadvertent deposition of injectable filler or fat transplant material into the draining veins that supply the back of the eye. Advance warning of this danger zone means injectables may be deposited in a safer location. Fat transplants and silicone pads around the orbit occasionally put pressure on the venous return resulting in tissue discoloration and edema from venous obstruction, while emboli to the ophthalmic arteries cutting off blood supply to facial regions cause death and sloughing of the affected ischemic skin. Vascular occlusion or insufficiency may be documented by Doppler studies and successful therapeutic relief documented in real time. Advanced 3D Doppler systems allow for histogram vessel density measurement of neoplastic angiogenesis (Fig. 5.1). This baseline

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Fig. 5.2  Linear nerve outlined by arrows

neovascularity is used as a treatment surrogate endpoint allowing for image-guided clinical reevaluation and timely correction of therapy (Fig. 5.2) [3].

5.5 Glandular Cancer Imaging Updates It is well established that non-dermatological malignancies have dermal manifestations either directly or indirectly. Breast cancer invading the lower dermis and nipple discovered with high-­ resolution probes signifies that the tumor has spread further than clinically anticipated. That finding is essential for detecting the newly discovered entity of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This capability is also vital for diagnosing the recent epidemic of male breast cancer occurring in our 9/11 First Responders arising near the mammographically difficult area of the nipple areolar complex. Prostate cancer clearly identified by 4D delimited by the capsule and of low vessel density is being followed serially in 6-month intervals. Subsequent capsular invasion or increase in vessel density on histogram analysis requires urologic measures. Bladder cancer is evaluated

concomitantly with the prostate and neovascularity and wall invasion noted before surgical referral. Testicular and thyroid tumors are similarly evaluated by 3D Doppler investigation protocols.

5.5.1 Contrast Enhanced Ultrasound (CEUS) In 1990, Dr Rodolfo Campani, director of the University of Pavia Radiology Department, developed ultrasound contrast enhanced cancer imaging for liver tumors followed by Drs. Cosgrove (London), Lassau (Paris), and Catalano (Naples) for breast, prostate, and melanoma. CEUS is currently used worldwide but not fully FDA approved in the United States. Microbubble, safe media show tumor neovascularity with exquisite detail and are used to evaluate therapeutic response in solid organ disease. This is important since the RECIST studies demonstrated that tumor enlargement during treatment may be related to apoptotic cell death with cystic degeneration or immune cell infiltration destroying malignant tissue. Co-existing benign disease may be indistinguishable from and integrated into the tumor mass. Doppler ultrasound or CEUS reliably verifies decreased angiogenesis in these

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5  Bard: Aesthetics—4D Facial Nerve Biomicroscopy

cases instead of using contrast CT or DCE-MRI for confirmation. Thermal treatments such as cryotherapy, HIFU, photodynamic treatment, or laser ablation are designated complete when perfusing cancer arteries are no longer visible.

5.5.2 Margin Delineation Advances in laser/optical devices allow near microscopic tissue analysis of the cells by rapid, non-invasive testing. Real-time microscopy is performed during surgery to assure that the tumor border is clear in cases of skin cancer, and future use in breast and prostate cancer treatment is under clinical study. Prostate, thyroid, and breast cancers are now treated robotically, and we predict other malignancies to be digitally ablated in the near future [4].

5.6 Autoimmune Disease and Cancer Abnormal immune responses that initially appear in the skin are associated with increased cancer incidence. Inflammatory vessels in psoriasis and infection are visibly cataloged since successful treatment is quantified by measured decrease in the number and type of abnormal vessels. High vascular immune vessel density is proportional to increased risk of future neoplastic tissue manifestations. Many arthritic conditions have coexistent dermal components alerting us to the probability of more extensive subclinical joint involvement. Botanical and cosmeceutical formulations have ameliorated many inflammatory diseases and possibly prevented malignant conditions, and their effect may be monitored before more aggressive approaches are initiated [5–11].

5.7 Treatment Standard procedures include surgical excision, photodynamic therapy, curettage with or without electro dissection, and Mohs Micrographic

Surgery (MMS). Topical treatments are 5-fluorouracil cream and imiquimod for low risk, superficial lesions. Immunotherapies have proven highly effective in the case of malignant melanoma although accompanied by significant side effects such as confusion and cutaneous disorders. New options with pulsed electromagnetic field technologies are non-invasive and have been effective in treating inflammatory disorders such as psoriasis, rosacea, and eczema. Minimally invasive injectables using an alternative to stem cells are exosomes to be discussed later in the chapter.

5.8 Radiation History The discovery of X-rays by Roentgen in 1896 allowed for the application for breast cancer treatment by Dr Emil Grubbe with this therapy in the same year. In 1898, the Curies discovered radium due to its elemental ionizing radiation on film. The first successful treatment of skin cancer occurred in 1899. The technology evolved from X-ray tubes and radium sources to high energy radioactive elements like cobalt and cesium. Low megavoltage generators and high megavoltage linear accelerators along with particles (electron beam and protons). Brachytherapy (BT) added remote afterloading devices, and miniature X-ray tubes generated electronic brachytherapy (EBT).

5.9 Functional Treatment Biology Radiation produces free radicals that damage DNA as the electromagnetic energy disrupts mitosis in rapidly dividing cells. While normal cells can repair damage, treated cancer cells cannot divide and are considered inactive or sterilized. This means that cancer cells that grow slowly will die slowly, and the tissues will look like active cancer but are, in fact, “sterile” or biologically inactive or dead, while appearing functional to the pathologist. Therefore, a biopsy

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may be “positive,” while the cancer is biologically inactive and potentially cured. Similarly, the size of a treated tumor poorly correlates with treatment success since edema from dying cells or infiltration with T cells, and other immunologic tissue can transiently enlarge the tumor mass while it is biologically “dead” [12–14]. Superficial radiation therapy (SRT)for non-­ melanoma skin cancer has been increasing in use with the aging population and portable units suitable for the office-based setting; while in use since the 1900s, it declined in use with the advances in MMS.  The precision image-guided radiation technologies are now achieving higher clinical application due to the cosmetic benefit and minimal side effects. While SRT uses low energy photons with limited penetration, the new focused “proton” beams are targeted precisely and limit surrounding tissue damage in spite of very high energy and may be used more frequently in more aggressive subtypes. Of note, 3D Doppler ultrasound not only establishes tumor depth and response to therapy, but assesses the malignant aggression potential using the specific echo pattern and neovascular findings characteristic of dangerous lesions. It has been used as a template for the image guidance coordinates for radiation therapy planning [13, 14]. HIFU and LASER treatments are used sporadically in cases where other options are not feasible and anecdotally have had good results.

5.10 Treatment Verification The overall recurrence rate analysis by Cognetta of 1715 NMSCs (BCC and SCC) was 1.9% [15]. Another study by Shulte on 1276 NMSCs showed a combined rate of 5.1% [16]. A paper by Zagrodnik using BCC histopathology for superficial, nodular, and sclerosing (morpheaform) cell types revealed a 5 year recurrence rate of 11.8, 2.8, and 27.7%, respectively [17]. More aggressive histopathologic types recurred up to 27%, and this in part may be explained by tumor not treated since it was outside the treatment field as in

R. L. Bard and P. Dreschnack

satellite, in transit, or more distant or deeper subcutaneous metastases not detected by the available imaging technology at the time. The vascular measurement parameters in OCT and RCM add another measure of treatment success by verifying absent blood flow in previously non-­ treated neovascular tumor tissue. Future tumor neovascularity assessment will use the (off label FDA approved) contrast enhanced ultrasound (CEUS) for advanced quantification.

5.11 Cosmetic Factors Cancers of the face  – ears, eyes, nose, perioral, and other visible areas – are good candidates for SRT where treatment may have significant cosmetic consequences. Common side effects are radiation dermatitis, erythema, and mild discomfort. Late reactions include hyper/ hypopigmentation, telangiectasias, and atrophy. Most patients are elderly and multiple treatments generally are a hardship. Fewer more intense sessions will cause skin damage but must be balanced against longevity, treatment effect, and cosmesis since the curative dosage is difficult to ascertain [18]. Since the cosmetic effect may be better than surgery, there is a trend to SRT use as a first-line treatment, except for deep tumor invasion, aggressive tumor histology, previously irradiated lesions, and some type of NMSC occurring in organ transplant patients. SRT is superior to electron beam radiotherapy (EBRT) and electronic brachytherapy (EBX) for most cases of NMSC.  Keloids may be successfully treated with few side effects and good functional return [19]. SRT is contraindicated in micronodular BCC, sclerosing BCC, recurrent BCC, and poorly differentiated SCC or desmoplastic SCC with/without perineural spread [20]. Since most BCC is facial, better results may be obtained with small field MRI [21] and ultrasound fusion-guided MRI targeting [22]. Verification of clinically acceptable treatment response has been studied by Markowitz [23].

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Fig. 5.3  The echogenic facial nerve is demonstrated in 3 orthogonal planes

5.11.1 4D Nerve Mapping While some nerves course near arterial structures, many diverge at a distance and are hard to differentiate with imaging from the subcutaneous fasci, ligaments, and tendons. Aside from iatrogenic nerve injury, a recent use is the treatment of Bell’s Palsy which is the most common form of idiopathic facial paralysis of the 7th cranial nerve thought to be caused by a viral or autoimmune condition. This affects middle-­aged patients in the equal distribution between male and female sexes. Although spontaneous resolution within months is usual, some cases may be protracted for years or even a lifetime. Mesenchymal stem cells or exosomes injected around the facial nerve

in the preauricular tissue and repeated after interval have been successfully performed diminishing inflammation and promoting recovery [24]. 4D imaging is able to distinguish branches of the extracranial 7th nerve from tendons, fascia, and ligaments with the aid of motion that moves muscle and tendons more vigorously than the relatively fixed submillimeter nerve bundles with very high-resolution imaging. Exosomes with their regenerative and immunomodulatory properties are used in dermatology for wound healing, stimulating hair growth, psoriasis, and atopic dermatitis [25] and may prove useful in the newly recognized role of nerve cells activation in pruritic conditions (Figs.  5.3, 5.4, 5.5, 5.6, 5.7 and 5.8) [26].

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Fig. 5.4  The echogenic nerve is adjacent to the SMAS

Fig. 5.5  The echogenic linear nerve abuts the boney cortex

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5  Bard: Aesthetics—4D Facial Nerve Biomicroscopy

Fig. 5.6  The tubular nerve lies deep to the SMAS

Fig. 5.7  The echogenic nerve lies deep to the muscle

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Fig. 5.8  The nerve lies between the muscle layers

References 1. Ewing J. Neoplastic diseases. London: WB Saunders; 1940. 2. Lassau N, Koscielny S, Avril M, Margulis A, Duvillard P, Baere T, Roche A, Leclere J.  Prognostic value of angiogenesis evaluated with high frequency and color Doppler sonography for preoperative assessment of melanomas. AJR. 2002;178:1547–51. 3. Cornud F, Hamida K, Flam T, Helenon O, Chretien Y, Thiounn N, Correas J, Casanova J, Moreau J. Endorectal color Doppler sonography and endorectal MR imaging features of non palpable prostate cancer. AJR. 2000;175:1161–8. 4. Bard R. Dynamic contrast enhanced MRI of prostate cancer. New York: Springer; 2009. 5. Awad AB, Fink CS. Phytosterols as anticancer dietary compounds: evidence and mechanism of action. J Nutr. 2000;130(9):2127–30. 6. Toda S, Shirataki Y.  Inhibitory effects of Astragali radix, a crude drug in oriental medicines, on lipid peroxidation and protein oxidative modification by copper. J Ethnopharmacol. 1999;68(1–3):331–3. 7. Wang D, Shen W, Tian Y, Sun Z, Jiang C, Yuan S.  Protective effect of active components extracted from radix Astragali on human erythrocyte membrane damages caused by reactive oxygen species [article in Chinese]. Zhongguo Zhong Yao Za Zhi. 1996;21(12):746–8, 763. 8. Chan MM, Mattiacci JA, Hwang HS, Shah A, Fong D. Synergy between ethanol and grape polyphenols, quercetin, and resveratrol, in the inhibition of the

inducible nitric oxide synthase pathway. Biochem Pharmacol. 2000;60(10):1539–48. 9. Chakraborty S, Roy M, Bhattacharya RK. Prevention and repair of DNA damage by selected phytochemicals as measured by single cell gel electrophoresis. Environ Pathol Toxicol Oncol. 2004;23(3):215–26. 10. Mertens-Talcott SU, Bomser JA, Romero C, Talcott ST, Percival SS. Ellagic acid potentiates the effect of Quercetin on p21waf1/cip1, p53, and MAPKinases without affecting intracellular generation of reactive oxygen species in vitro. J Nutr. 2005;135:609–14. 11. Mertens-Talcott SU, Talcott ST, Percival SS.  Low concentrations of quercetin and Ellagic acid synergistically influence proliferation, cytotoxicity and apoptosis in MOLT-4 human leukemia cells. J Nutr. 2003;133:2669–74. 12. McGregor S, Minni J, Herold D, et  al. Superficial radiation therapy for treatment of nonmelanoma skin cancers. J Clin Aesthet Dermatol. 2015;8(12):12–4. 13. Bard RJ, editor. Image guided dermatologic treatment. Berlin: Springer; 2019. p. 43–56. 14. Padhani A, Petralia G.  Whole body MRI.  In: Proceedings of 18th Annual International Cancer Imaging Society, Menton; 2018. 15. Cognetta A, Howard B, Heaton H, et  al. Superficial Xray treatment in the treatment of basal and squamous cell carcinoma. JAAD. 2012;67:1237–41. 16. Schulte KE, Lippoid A, Auras C, et  al. Soft Xray therapy for cutaneous basal and squamous cell carcinomas. JAAD. 2005;53:993–1001. 17. Zadronik B, Kempt W, Seifert E, et  al. Superficial radiotherapy for patients with basal cell carcinoma. Cancer. 2003;98(12):2708–14.

5  Bard: Aesthetics—4D Facial Nerve Biomicroscopy 18. Zaorsky N, Lee CT, Zhang E, et al. Hypofractionated radiation therapy for basal and squamous cell skin cancer: a meta-analysis. Radiother Oncol. 2017;125(1):13. 19. Nestor M, Berman B, Goldberg D, et  al. Consensus guidelines on the use of superficial radiation therapy for treating nonmelanoma skin cancers and keloids. J Clin Aesthet Dermatol. 2019;12(2):12–8. 20. Hafner J.  Superficial radiotherapy to treat skin cancer. In: Proceedings 37th Annual ISDS Meeting 2016, Amsterdam; 2016. 21. Budak M, Weir J, Yaap P, et al. High resolution microscopy-coil MR imaging of skin tumors. Radiographics. 2015;35(4):1077–90.

49 22. Bard R. MRI imaging of skin cancer. In: Proceedings of the 2020 AIUM Annual Meeting of the American Institute of Ultrasound in Medicine, New York; 2020. 23. Markowitz O.  Patient-driven management using same-day noninvasive diagnosis and complete laser treatment of basal cell carcinomas: a pilot study. Lasers Surg Med. 2019;51(10):24–9. 24. Dreschnack P, Scott M, Bochenek C. Bell’s Palsy and stem cell therapy. J Regen Med. 2020;9(1):156–8. 25. Quinones M, Sanabria R, Sanchez M, et al. Rôle of exosome derived cells in dermatology. Front Cell Dev Biol. 2021;2(2):12–21. 26. Bard R, Gettz L, Stoff J, et al. 3D Doppler imaging of inflammatory skin disease. In: 4th ISDS Symposium at New York Academy Medicine; 2021.

6

Facial Rejuvenation/Non-Surgical Procedures Beth Haney

Abstract

Keywords

Non-surgical aesthetic treatments are popular options for men and women who want to maintain a youthful and healthy appearance without enduring a surgical procedure. The available treatments include neurotoxins, or botulinum neurotoxin type A (BoNT/A) injections, dermal filler injections, laser treatments, radiofrequency procedures, and topical applications. Botulinum neurotoxin type A (BoNT/A) for cosmetic use, commonly known as Botox®, Dysport®, and Xeomin®, is the most commonly performed non-surgical aesthetic procedure in the world. The action of BoNT/A results in smoother skin due to the relaxation of the facial muscle fibers. Alternatively, dermal fillers replace facial volume and are the second most requested, non-surgical aesthetic procedure worldwide. Practical knowledge of BoNT/A and available temporary dermal filler pharmacology are important aspects of aesthetic practice. This chapter will provide information on the use of neurotoxin and temporary dermal filler procedures including mechanisms of action, potential complications, and future uses.

Botox · Dysport · Xeomin · Neurotoxin complications · Botulinum toxin type A (BoNT/A) · Eyelid ptosis · Brow ptosis · Temporary dermal filler · Hyaluronic acid · G-prime · Crosslinked · Poly-l-lactic acid (PLLA) · Calcium hydroxyapatite (CaHA) · Dermal filler pharmacology · NASHA · PLLA · CaHA · Muscle memory · Radiofrequency · Ultrasound · Laser emitting device · LED

B. Haney (*) Department of Nursing, USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA e-mail: [email protected]

6.1 Neurotoxins: Botulinum Toxin Type A (BoNT/A) 6.1.1 Mechanism of Action The facial muscles are the only muscle group in the human body that insert directly into the skin [1, 2]. The repeated contraction of facial muscles results in lines (rhytids) both at rest and during facial expression. These types of lines are categorized as dynamic lines because they are created by movement. The resting face that is free from lines etched in the skin is a more youthful looking face, and with repeated use, BoNT/A can result in smooth line-free skin. This aesthetically pleasing result is an outcome of the temporary relaxation of facial muscles from BoNT/A treatments.

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To comprehend how BoNT/A works in the musculature of the face and neck, an understanding of the synaptic communication and neurotransmitter relationship is necessary. The five commercial brands of BoNT/A, Botox®, Dysport®, Xeomin®, Daxxify®, and Jeuveau®, all work in similar ways. Soluble N-ethylmaleimide-­ sensitive factor adaptor proteins (SNAPs) and SNAP receptors (SNAREs) are the main targets of BoNT/A [3]. Injection of the BoNT/A molecule into the muscle blocks neuromuscular transmission by binding to surface receptors on motor nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine [4]. This inhibition occurs as the pH-induced translocation of the toxin light chain to the cell cytosol cleaves SNAP-25, a presynaptic protein that is crucial in

B. Haney

the successful docking and release of acetylcholine from vesicles within nerve endings [5]. The result is a decrease in the target muscle activity ultimately resulting in less dynamic line formation (see Figs. 6.1 and 6.2). In addition, there is some evidence the affected muscle might atrophy, and subsequent re-innervation of the muscle occurs, thus slowly reversing BoNT/A action. Transmission gradually begins as the neuromuscular junction recovers from cleavage of the SNAP-25 and new nerve endings are formed [4–9]. This phenomenon may be associated with the term “muscle memory” when referring to the longer-lasting cosmetic effect of the BoNT/A on select patients [10]. The pharmacological effect of BoNT/A is caused by the cleaving of SNAP25 and subse-

Fig. 6.1  Normal transmitter (acetylcholine) release in muscle. (Used with permission from Professor Bal Ram Singh, PhD, Institute of Advanced Sciences)

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Fig. 6.2  Mechanism of action of onabotulinumtoxinA. Note the cleaving of the SNAP-25 complex. (Used with permission from Professor Bal Ram Singh, PhD, Institute of Advanced Sciences)

quent decrease in the formation of SNARE complexes and blocking acetylcholine release from the peripheral nerve cells into the neuromuscular junction (Figs. 6.1 and 6.2) [3, 5, 11]. Relaxation of the targeted muscle or muscle group temporarily leads to smoother overlying skin because the muscle is no longer able to fully contract and create rhytids. The smoothing results are temporary and last approximately 3 to 4  months, although the medication package insert states up to 6 months [8, 9, 12]. Of the five types of BoNT/A, onabotulinumtoxinA (Botox®) has 28 indications in 100 countries for treatment of a variety of conditions other than cosmetic applications including bladder spasms, hyperhidrosis, cervical dystonia, facial spasms, migraine headaches, blepharospasm, and depression. OnabotulinumtoxinA is also the most

widely studied neurotoxin for therapeutic and cosmetic purposes, with over 2800 articles and over 400 peer-reviewed articles worldwide between 1986 and 2013 [8, 13].

6.2 Potential BoNT/A Adverse Reactions and Selected Imaging Technology for Treatment Treatments with BoNT/A create a more refreshed, smooth, and alert appearance when done correctly. Unwanted side effects such as eyelid or eyebrow ptosis, asymmetry, or hematoma formation can occur if the practitioner is not properly trained or has little experience. However, some less significant side effects can still occur even in

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experienced hands such as swelling, redness, or bruising. Bruising can be almost entirely avoided with the use of imaging technology such as the laser emitting diode (LED) or near infrared (NIR) devices that use targeted light to illuminate superficial blood vessels under the skin surface. Available devices include AccuVein®, Veinlite®, and Intellivision, among others, and are used in hospitals, medical offices, and private practices to locate vessels for intravenous injection, phlebotomy, or aesthetic work (Fig. 6.3). These devices work by using near infrared light-emitting diodes (NIR-LED) to visualize superficial veins because the hemoglobin absorbs the emitted light and forms an image on the skin surface. The NIR imaging uses light rays to penetrate into skin and acquire the images of venous structures and allows a deeper look below the skin for better contrast between skin and veins. In the electromagnetic spectrum, there is a low absorption window within NIR region in which light can penetrate deeper into the skin and tis-

Fig. 6.3  The near infrared (NIR) light illuminates vessels under the skin and can help prevent bruising. (Photo: B. Haney, DNP, FNP-C, FAANP, FAAN)

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sues because of the low absorption range of hemoglobin, oxy-hemoglobin, and water which are main absorbers of radiations in skin [14]. This demonstrates hemoglobin affects visible light absorbance. In another example, a commonly used medical device, the pulse oximeter, measures absorption ratios of different wavelengths of oxygenated and deoxygenated blood and provides useful diagnostic information in the primary and acute care settings [15]. Light emitting imaging technology devices are very helpful in  locating veins through the varying degrees of light absorption and are effective ways to help prevent bruising in aesthetic practice by avoiding vein puncture. The other two common side effects, swelling and redness at injection site(s), are short-lived and do not typically last longer than 24–48 h, whereas bruising can be visible for weeks. Several more and potentially longer-lasting side effects are eyelid and/or eyebrow ptosis or an asymmetrical outcome. Eyelid ptosis is a potential side effect of BoNT/A treatment that results in a heavy lid sensation and a sleepy appearance and can last for days or weeks. This unfavorable side effect is caused from diffusion of the BoNT/A into the levator palpebrae superioris and can be avoided by using precise injection technique [8–10, 12, 16]. This untoward outcome is easily avoided by accurate placement of the BoNT/A no closer than 1 CM above the bony orbital rim and injecting medial to the mid-­ pupillary line when treating the glabella area [16, 17]. The application of pressure under the orbital bone during injection of the corrugators may help prevent eyelid ptosis from solution spread during treatment. If necessary, eyelid ptosis can be treated with prescription apraclonidine or oxymetazoline (Upneeq®) drops that help to elevate the upper eyelid through stimulation of an adrenergic muscle located near the levator muscle called Muller’s muscle [17–19]. These drops can be used as directed until the ptosis resolves, usually within minutes for oxymetazoline or several weeks for apraclonidine. Eyebrow ptosis, on the other hand, can last for several months and results from too high a dose

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in the frontalis or injection sites placed too low. The patient might complain of heavy, flattened, dropped brows, and a completely immobile forehead with possible puffiness to the eyelids. The practitioner can avoid brow ptosis by injecting the procerus and corrugator muscles with the frontalis to ensure the counterbalance of depressor and elevator muscles [10, 16, 20]. In addition, injecting a small amount 1  CM above the orbital rim at the mid-pupillary line will help prevent brow ptosis [17, 21]. Further, injection of a low dose of BoNT/A at the lateral tail of the brow and procerus along with the frontalis can help prevent brow ptosis. Because of the depressor effect of treating the frontalis muscles, it is not recommended to treat the frontalis exclusively [10, 16, 17, 20]. Occasionally, patients might have a naturally asymmetrical appearance, and BoNT/A treatments are an effective option to correcting this issue. However, practitioners must be cautious and mindful that BoNT/A can create asymmetry if accurate placement is not used. For example, injections at different heights on the forehead might lead to one brow lower than the other on a patient with naturally symmetrical brows. Or, in addressing lip lines or nasalis lines, if too large a dose is used, lip dysfunction can result from diffusion of too much BoNT/A into the orbicularis oris and/or levator labii superioris muscle fibers. The patient may notice asymmetrical smiling, difficulty pronouncing certain words, inability to whistle or play musical instruments, and/or impaired drinking and eating [17, 22].

6.3 Potential Future Uses for Botulinumtoxin Type A (BoNT/A) On-label uses of BoNT/A on the face include the glabella and orbital areas. The off-label cosmetic applications of BoNT/A include the infra-orbital muscles to treat fine wrinkles, the platysma to treat banding in the neck, the mentalis to treat dimpling of the chin, the depressor anguli oris to lift the oral commissures, and the nasalis muscle to treat bunny lines [23].

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BoNT/A currently has other medical uses and is being studied for approval for a variety of indications by the US Federal Drug Administration (FDA). One novel FDA-approved indication is axillary hyperhidrosis (excessive underarm sweating), and some additional off-label dermatologic uses include acne, rosacea, scar reduction, pain, and psoriasis [24–26]. Researchers are currently considering multiple investigational applications of BoNT/A in medical specialties other than dermatology, including for treatment of psychiatric, gastroenterological, neurologic, gynecologic, and ophthalmic conditions [27]. This section will only focus on potential future uses of BoNT/A in aesthetic practice. However, a chart listing many of the medical conditions currently treated with BoNT/A is included in this section to demonstrate the emerging potential applications of BoNT/A (Table 6.1).

6.3.1 Hyperhidrosis Excessive underarm sweating (axillary hyperhidrosis) is an approved indication for onabotulinumtoxinA (Botox®) and has been a welcome addition to the group of conditions treated by BoNT/A.  Axillary hyperhidrosis (AH) is an embarrassing ailment for affected patients. The condition is the result of an overproduction of sweat beyond necessary body cooling, and approximately 3–5% of people in the United States experience this bothersome disorder [28]. Most people with AH become aware before age 25; however, those who suffer with palmar hyperhidrosis (PH) usually notice excessive palmar sweating prior to puberty [29]. In addition to BoNT/A, there are several approaches used to help control AH including topical application of aluminum chloride products, radiofrequency, or ultrasound treatments; and in intractable cases, surgical intervention. BoNT/A treatment is reserved for patients who fail the more conservative treatments such as antiperspirants [29]. The typical BoNT/A treatment for AH consists of 15–25 subdermal or subcutaneous injec-

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56 Table 6.1  Therapeutic uses for botulinum neurotoxin Ophthalmology  1. Strabismusa,b,c  2. Nystagmus Neurology  1. Blepharospasma,b,c  2. Cervical dystoniaa,b,c  3. Writer’s crampb  4. Laryngeal dysphoniac  5. Hemifacial spasma,b,c  6. Tremor (essential, Parkinsonism)  7. Tics  8. Bruxism  9. Focal spasticitya,b,c: Upper and lower limb spasticity  10. Cerebral palsya,b Hyperhidrosisa,b,c  1. Focal: Axillary, palmar, plantar Hypersalivation  1. Sialorrheab (motor neuron diseases/amyotrophic lateral sclerosis)  2. Droolingb (Parkinsonian syndromes) Aesthetic (muscle)  1. Glabellar rhytidsa,b,c  2. Lateral canthus (orbital)a Pain  Muscular    1. Temporomandibular disorders    2. Low back pain  Non-muscular    3. Migrainea    4. Neuropathic pain    5. Trigeminal pain    6. Pelvic pain    7. Osteoarthritis Urology  1. Overactive bladdera,b,c (idiopathic or neurogenic detrusor over-activity)  2. Urinary retention  3. Bladder pain syndrome  4. Pelvic floor spasms  5. Benign prostate hyperplasia Gastroenterology  1. Chronic anal fissures Psychiatry  1. Depressiond Adapted from Pirazzini et al. [30] a USA approved indication b EU approved indication c Evidence-based therapeutic indication d To be evaluated

tion sites per axilla of 2 units onabotulinumtoxinA or 5u abobotulinumtoxinA; however, the doses may vary slightly [28–30]. Pain control at injection sites includes ice applied immediately prior to and during treatment or topical anesthetic cream applied 30  min prior to treatment. The duration of the effect of BoNT/A in the axillae tends to be longer than intramuscular injection of the facial muscles, lasting about 6–9 months. The longer duration is likely due to the stimulation by the sympathetic division of the autonomic nervous system on the sweat glands, with acetylcholine acting as neurotransmitter between nerve endings and sweat glands [28, 29]. Palmar hyperhidrosis can also be treated with BoNT/A successfully when topical hyperhidrosis remedies fail; however, studies are limited, and this is an off-label indication. Treatment of PH can be a painful procedure, and topical anesthetic is usually warranted, but BoNT/A treatment is well tolerated and may improve quality of life in people who suffer with hyperhidrosis of the axillae and hands [31].

6.3.2 Acne Acne is a common and often an embarrassing disease for both genders and can occur at various intervals during the lifespan from puberty through menopause. Treatments include topical and oral medications, acne washes, light-based treatments, and peels. One emerging use for intradermal BoNT/A is as an additional acne treatment, and it is currently being investigated [32]. Acne lesions form in the pilosebaceous unit and are influenced by hormones that lead to increased sebum production, and this increased sebum production leads to acne lesions and flares in susceptible individuals. Pore size has also been associated with sebum production [33]. Sebum production in human skin is increased through acetylcholine signaling; therefore, because BoNT/A blocks acetylcholine, sebum production is decreased. Literature supports that individuals with oily skin are more responsive to acetylcholine

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than those with normal skin because the concentration of acetylcholine receptors is higher in their sebaceous glands. For these reasons, BoNT/A intradermal injections significantly decrease sebum production in oily skin but not in those with normal skin [32, 34]. Another benefit of BoNT/A treatment in many people was the decrease in pore size [32, 34]. Pore size was found to be influenced by BoNT/A, and this can have a positive impact on the appearance of the skin. Oily skin, large pores, and scars add to the rough, uneven appearance of the skin and are problematic for many people who suffer with acne. Options to alleviate these concerns are increasing with the advancement of new uses and the advent of intradermal BoNT/A injections as an exciting new possibility for the treatment of acne [32, 35, 36].

6.3.3 Facial Scars Scarring is a concern in those who undergo surgical procedures or closure of traumatic wounds, especially on the face [24, 37]. Scars from facial wounds and incisions can be unsightly, particularly in areas where muscle movement is frequent. The mechanism of BoNT/A results in the relaxation of muscles; therefore, it is postulated that the use of BoNT/A before, during, or after facial surgical procedures would decrease the tension on the closed edges of the incision and result in an improved cosmetic appearance [24, 25, 38]. There is some evidence that injecting surgical sites with the typical pre-procedure anesthetic and vasoconstrictor (lidocaine with epinephrine), mixed with BoNT/A, decreases the number of injections while also resulting in immediate local muscle paralysis [37, 39]. This local paralysis leads to improved cosmesis of facial scars because the surrounding muscle tension is decreased [38]. The reconstitution of BoNT/A with lidocaine and epinephrine did not affect the longevity or effect of the BoNT/A, and muscle

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function returned after 3 months [39]. Although re-constitution of BoNT/A with an anesthetic and/or vasoconstrictor is not recommended by drug manufacturers, it might be an acceptable option for scar prevention in the future.

6.4 Temporary Dermal Fillers Globally, temporary dermal fillers are the second most requested, non-surgical facial aesthetic procedure behind BoNT/A treatments [40]. Practical knowledge of temporary dermal filler use, duration, and effect are important aspects of aesthetic practice, and the importance of understanding their intrinsic pharmacological aspects cannot be overemphasized. The practitioner must understand the various type(s) of filler used in the skin and tissues to achieve the most aesthetically pleasing and appropriate outcome. There are several different categories of fillers, (1) temporary or biodegradable, (2) stimulant, and (3) permanent or non-biodegradable fillers. Each type of filler has specific requisites, and the choice depends on several factors including the desired result, skin condition, and average product longevity to determine which is used on the patient. Permanent dermal filler discussion is beyond the scope of this chapter; however, temporary dermal fillers will be the focus, and some of the information provided herein will pertain to all types of dermal filler products. The temporary fillers composed of hyaluronic acid (HA), calcium hydroxyapatite (CaHA), and poly-L-­ lactic acid (PLLA) fillers will be discussed as they are most commonly used by aesthetic practitioners. Although all three of these temporary filler products are popular, only one has the distinguishing property of reversibility, the HA temporary fillers. The ability to reverse HA fillers easily with hyaluronidase makes them an attractive option for many providers and patients.

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6.5 Hyaluronic Acid (HA) Fillers Hyaluronan, or HA, is a naturally occurring linear polysaccharide that is found in the skin, epithelial, connective, and other tissues. Hyaluronan is innate in human skin and lacks a protein component so it does not require allergy skin testing prior to injection, making it a convenient product to use for facial applications. HA is hydrophilic and is able to bind 1000 times its molecular weight in water so it makes a good substance for adding volume to skin and facial tissue [41, 42]. In youth, humans have an abundance of HA in the skin, and it contributes to the fullness in skin appearance. As we age, the amount of naturally occurring HA in skin decreases, and subsequently, we begin to produce less HA. This phenomenon plays an important role in the appearance of aging, wrinkle formation, decreased tissue elasticity, and hydration [41, 43]. In its natural state, HA has an approximate half-life of 24–48 h before it is broken down and metabolized in the liver into water and carbon dioxide [41, 43–46]. In the skin, HA is broken down by hyaluronidase and free radicals [42, 43, 47]. Natural HA injected into the skin would break down quickly through enzymatic action so would not be appropriate for cosmetic purposes due to its short duration and minimal effect in aesthetic patients. Advanced processes have been developed through available technology that have led to longer-lasting HA products that can endure for months or years. The HA molecules are stabilized using crosslinking technology with hydroxyl groups and provide the long-lasting qualities of modern HA fillers. The crosslinking agent in the Restylane® and Juvederm® HA families of products is 1,4-butanediol diglycidyl ether (BDDE) [42, 43, 48, 49]. These developments have made injectable HA stable and more resistant to break down. The different HA families of filler are developed using slightly different technologies. The Juvederm® family of products are sterile, biodegradable, non-pyrogenic, viscoelastic, clear, colorless, homogenized gel implant produced by

Streptococcus equi bacteria, developed through a fermentation process, and crosslinked with BDDE [42, 48]. The Restylane® family of products are made of hyaluronic acid generated by a Streptococcus species of bacteria, also chemically crosslinked with BDDE, stabilized and suspended in phosphate buffered saline [49]. Belotero Balance® is a HA product that is sterile, non-pyrogenic, viscoelastic, homogenous, clear gel implant bacterially fermented, manufactured from Streptococcus bacteria, and crosslinked with BDDE [50]. The HA fillers also differ in particle size, crosslinking of the HA molecules, the amount of crosslinking in the product, as well as the G-prime or viscosity of the product. These product features guide the practitioner in choosing the appropriate filler for specific effects ranging from smoothing superficial lines to bone augmentation [41, 42, 50].

6.5.1 G-Prime and Particle Size G-prime is a measurement of the stiffness of the hyaluronic gel product and helps determine the appropriate area and depth for placement in the skin. Generally, thicker products are not suitable for placement in the superficial layers of skin due to the possibility of long-lasting swelling, uneven result, and the Tyndall effect – residual visibility of the product as a bluish tint [41]. G-prime also contributes to the increased longevity of the effect of the HA products, i.e. the higher the G-prime, the longer the filler might last [41, 42, 44, 47]. The modern, crosslinked HA dermal fillers of the Belotero®, Juvederm®, and Restylane® families of products, are frequently used to replace volume or soften fine lines in the face. These fillers include both crosslinked or high weight, and non-crosslinked or low weight, HA molecules within their gel vehicle. The higher the concentration of crosslinked HA molecules, the longer the effect will last [41, 42, 47, 51, 52]. After injection into the skin, the non-­ crosslinked hyaluronic acid is quickly broken down, and only the crosslinked, larger molecular

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weight polymers are left behind. The reason for 6.6 Calcium Hydroxyapatite the low weight, non-crosslinked molecules in the (CaHA): Radiesse® product allows easier injection through the needle or cannula [42, 43]. If the gel consisted of Calcium hydroxyapatite (CaHA) is the generic purely large weight, crosslinked molecules, the name for the temporary filler, Radiesse®, and is product would not be conducive to injection made of the same compound as human bone [57, through a small caliber needle [52]. 58]. Initially, CaHA was used as a treatment for Particle size is another relevant aspect of the urinary stress incontinence, as a radiographic HA fillers. Particles are formed into specific sizes marker, and for vocal cord restoration [59–62]. through different processes employed by each CaHA was first approved in the United States in manufacturer. In one sizing method, particle size 2006 for aesthetic treatment of naso-labial folds is created through a process where crosslinked (NLF) and lipoatrophy of HIV [57]. HA is pushed through a customized screen to CaHA is an opaque, sterile, non-pyrogenic, create different, specific sizes of the particles. semi-solid, cohesive implant, whose principal Smaller sizes are made into lower G-prime, or component is synthetic calcium hydroxyapatite less viscous products, whereas the larger particle suspended in a gel carrier of glycerin, sodium sizes are made into the higher G-prime, or more carboxymethylcellulose, 0.3% lidocaine hydroviscous products [42, 44]. To date, there is no sci- chloride, and sterile water [63]. CaHA is made up entific data on which process yields the preferred of 70% carrier gel, and the remaining 30% is longevity profile or outcome. CaHA microspheres that are suspended in an The concentration of the different HA prod- injectable gel. These elements of CaHA make it ucts is listed in Table 6.2 [7, 44, 48–50, 53–56]. radiopaque and visible on CT scans and x-ray HA fillers break down slowly over time, but studies [59]. CaHA injectable implant (1.5 cc and on occasion, a small number of patients may 0.8 cc) has a calcium hydroxyapatite particle size experience a diminished effect within an range of 25–45 μg and should be injected with a unreasonably short time period. Comparison of 25 gauge outer diameter to 27 gauge inner diamclear, pre-treatment photographs with pre-­ eter needle [41, 63]. treatment, post-treatment, and recent photographs During injection of CaHA into the skin, the generally demonstrates the effect of the filler. gel evenly distributes the CaHA microspheres for Visual documentation is very important to a uniform placement and dispersal. The product capture objective images, especially in aesthetic requires no skin testing prior to administration, practice. The subjective patient perception is one and this makes it a convenient choice for facial of the myriad of reasons to take pre-treatment augmentation [58]. The carrier gel dissipates photographs. within several weeks, and the CaHA microspheres remain in the tissue at the injection site until they Table 6.2  Various concentrations and particle sizes of slowly breakdown into calcium and phosphate HA fillers ions [57]. After injection of the product, the carProduct Concentration of HA Particle size rier gel is broken down and phagocytized. The Restylane 20 mg/mL 250 μm remaining CaHA particles act as a support Restylane Lyft 20 mg/mL 650 μm substance or scaffolding that allows for new colRestylane Refyne 20 mg/mL – lagen formation [41]. Restylane Defyne 20 mg/mL – Post-market studies indicate CaHA can last up Juvederm 24 mg/mL Varies to 2 years, and it also induces collagenesis when Juvederm ultra 24 mg/mL Varies correctly placed in the skin, and in susceptible plus patients, this collagenesis might contribute to the Juvederm Voluma 20 mg/mL – lasting effect of this filler [41, 57, 63]. However, Belotero 22.5 mg/mL N/A While some have the same concentration, larger particle in older patients with less skin elasticity, size create longer-lasting effects collagenesis from CaHA placement may be

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decreased, and these patients might require larger amounts of product or more frequent treatments.

6.7 Poly-l-Lactic Acid (PLLA): (Sculptra®) Poly-l-Lactic Acid (PLLA) is the generic name for the temporary filler, Sculptra®, and was first FDA approved in 2004 for treatment of facial lipoatrophy associated with Human Immunodeficiency Virus (HIV) [64, 65]. PLLA is the active and durable ingredient and is a synthetic biodegradable polymer that is used for soft tissue augmentation. It is a freeze-dried powder of PLLA and must be rehydrated with 5 mL sterile water per vial prior to injection. The particle size of PLLA is 40–60 μm [41, 66]. Stimulation of an inflammatory tissue response produced by PLLA leads to collagen deposition in the skin. Sculptra® is composed of PLLA microparticles, sodium carboxymethylcellulose, and nonpyrogenic mannitol [66, 67]. The package insert recommends product rehydration for 2  h; however, 48  h has proven more successful clinically by reducing the incidence of undesired nodule formation. The volume correction outcome with PLLA has been shown to last up to 2 years [67, 68]. After the product is injected, the PLLA component is hydrolyzed into lactic acid monomers that induce a localized foreign body tissue response through the recruitment of monocytes, macrophages, and fibroblasts. Subsequently, a capsule is formed around each microsphere as the lactic acid is metabolized, and the result is collagen deposition by the host fibroblasts. The new tissue volume is the result of dermal fibroplasia and increased dermal thickness [65, 67]. PLLA is biodegradable and biocompatible and has been used in medical devices such as absorbable sutures and mesh [67]. Due to its unique mechanism of action, the volumizing effects of PLLA treatment will not be immediate, although the initial fullness from the sterile water diluent is temporarily noticeable, and patients usually require more than one treatment session [66, 67]. The initial fullness from injection of the

sterile water diluent typically resorbs within 24-48 h [68]. The novice injector is wise to avoid the temptation to bring the area to full corrected state when using PLLA because it generally requires more than one treatment session to allow time for adequate collagen formation [65, 67]. Therefore, a series of treatments is recommended to avoid overcorrection. The final outcome is dependent on the number of treatment sessions, and the patient should be informed visible PLLA effects can take up to 2 months. Patient expectations, possible side effects, and treatment outcomes of dermal fillers should be reviewed with the patient at every visit to ensure the patient understands the characteristics of the appropriate dermal filler for their aesthetic concern. PLLA has a unique mechanism of action and ingredient that requires practitioner knowledge of product handling and injection technique to avoid a poor outcome. Factors that can contribute to poor outcome and nodule/ papule formation while using PLLA include the following [41, 68]: 1. Placement of product that is too superficial. 2. Product injected into active muscles. 3. Inadequate product hydration time. 4. Poor suspension of particles. It is important to note that many aesthetic patients expect to see improvement quickly and they might become anxious or disappointed if the results are not clearly visible within a short amount of time. This concern has led some practitioners to use a HA filler at the same time of PLLA treatment so the patient will notice an immediate improvement [69].

6.8 Complications of Dermal Fillers Adverse reactions from temporary dermal fillers are generally classified as early onset (up to 1  week after treatment) or late onset (weeks to years after treatment). However, most delayed onset reactions are associated with the non-­

6  Facial Rejuvenation/Non-Surgical Procedures

biodegradable fillers such as silicone, polyacrylamide, and polymethylmethacrylate [41]. Early onset adverse reactions include injection site reactions, nodules, Tyndall effect (hyaluronic acid fillers), infection, hypersensitivity, and vascular compromise leading to tissue necrosis [41, 70]. Late or delayed onset adverse reactions include infection, biofilm formation, and granuloma formation; however, any or all of these can occur in temporary or non-­biodegradable filler types as well [41]. There are steps practitioners can take to avoid several of these complications such as obtaining a thorough patient medical history, properly preparing the skin for the procedure by cleansing and disinfecting the treatment area, using aseptic technique during the procedure, using appropriate amounts of product, and utilizing vessel visualization using technology. Laser emitting diode (LED) or near infrared (NIR) devices that use targeted light to illuminate superficial blood vessels under the skin surface are helpful in avoiding bruising (see earlier discussion). There are other technologies, such as ultrasound, that are useful in locating deeper anatomic structures and relationships. Ultrasound has been used in a variety of medical settings including cardiology, critical care, obstetrics and gynecology, and more recently, aesthetics. Using an ultrasound device can assist the aesthetic practitioner in locating deeper facial structures such as glands and, more importantly, vessels [71, 72]. Facial mapping of this extent offers an extra layer of patient safety and practitioner confidence. More detail is discussed in the Facial Danger Zones chapter.

6.9 Conclusion Dermal filler and BoNT/A treatments are the two most popular aesthetic procedures in the world and have proven to be effective for skin improvement, volume replacement, and overall appearance. Understanding product mechanisms of action, proper placement and technique, use of imaging devices when appropriate, and awareness and management of potential complications are

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crucial to success and will ensure the best outcome for the patient.

References 1. Vigliante CE. Anatomy and functions of the muscles of facial expression. Oral Maxillofac Surg Clin North Am. 2005;17(1):1–15. v 2. Tamura BM.  In: Issa BT, editor. Facial anatomy view for aesthetic fillers injections. Berlin: Springer International; 2018. 3. Rizo J, Sudhof TC.  The membrane fusion enigma: SNAREs, Sec1/Munc18 proteins, and their accomplices—guilty as charged? Annu Rev Cell Dev Biol. 2012;28:279–308. 4. Frevert J.  Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type a products. Drugs R D. 2015;15(1):1–9. 5. Aoki KR, Guyer B. Botulinum toxin type a and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions. Eur J Neurol. 2001;8(Suppl 5):21–9. 6. Daxxify medication guide. Revance Aesthetics. 2022. https://revance.com/wp-content/themes/allen-larsontheme/files/daxi-pi-andmed-guide.pdf. 7. Alam M, Tung R. Injection technique in neurotoxins and fillers: planning and basic technique. J Am Acad Dermatol. 2018;79(3):407–19. 8. Allergan. Botox cosmetic prescribing information. Package insert. 2017. 9. LLC MP. Xeomin Full Prescribing Information. 2018. 10. Carruthers J, Carruthers A.  The use of botulinum toxin type a in the upper face. Facial Plast Surg Clin North Am. 2006;14(3):253–60. 11. Patil S, Willett O, Thompkins T, Hermann R, Ramanathan S, Cornett EM, et  al. Botulinum toxin: pharmacology and therapeutic roles in pain states. Curr Pain Headache Rep. 2016;20(3):15. 12. Inc. IB.  Dysport Full Prescribing Information. 2017. 13. Mohindru A, Bulloch S, Kronfeld N, et  al. Analysis of clinical and non-clinical, peer reviewed, published studies investigating the use of commercially available botulinum toxins: an online literature review. In: Poster presented at: Second International Congress on Treatment of Dystonia (ICTD). 14. Shahzad A, Saad MN, Walter N, Malik AS, Meriaudeau F.  Hyperspectral venous image quality assessment for optimum illumination range selection based on skin tone characteristics. Biomed Eng Online. 2014;13:109. 15. Thom CS, Dickson CF, Gell DA, Weiss MJ. Hemoglobin variants: biochemical properties and clinical correlates. Cold Spring Harb Perspect Med. 2013;3(3):a011858.

62 16. Lorenc ZP, Smith S, Nestor M, Nelson D, Moradi A.  Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type a therapy. Aesthetic Plast Surg. 2013;37(5):975–83. 17. Carruthers A, Carruthers J.  In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Philadelphia, PA: Elsevier Saunders; 2005. p. 141. 18. Upneeq prescribing information. Upneeq.com. 2023. https://www.upneeq.com/wp-content/ uploads/2022/10/Upneeq-PI-IFU.pdf. 19. Wijemanne S, Vijayakumar D, Jankovic J. Apraclonidine in the treatment of ptosis. J Neurol Sci. 2017;376:129–32. 20. Carruthers A, Carruthers J. Eyebrow height after botulinum toxin type a to the glabella. Dermatol Surg. 2007;33(1):S26–31. 21. Kordestani R, Small KH, Rohrich RJ. Advancements and refinement in facial neuromodulators. Plast Reconstr Surg. 2016;138(4):803–6. 22. Carruthers J, Carruthers A.  Aesthetic botulinum a toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. 23. Carruthers J, Carruthers A.  Botulinum toxin a in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. 24. Goodman GJ. The use of botulinum toxin as primary or adjunctive treatment for post acne and traumatic scarring. J Cutan Aesthet Surg. 2010;3(2):90–2. 25. Gassner HG, Sherris DA, Otley CC.  Treatment of facial wounds with botulinum toxin a improves cosmetic outcome in primates. Plast Reconstr Surg. 2000;105(6):1948–53; discussion 54–5. 26. Baumeister JC, Papa G, Foroni F.  Deeper than skin deep—the effect of botulinum toxin-a on emotion processing. Toxicon. 2016;118:86–90. 27. Magid M, Keeling BH, Reichenberg JS. Neurotoxins: expanding uses of neuromodulators in medicine— major depressive disorder. Plast Reconstr Surg. 2015;136(5 Suppl):111S–9S. 28. Rosen R, Stewart T.  Results of a 10-year followup study of botulinum toxin a therapy for primary axillary hyperhidrosis in Australia. Intern Med J. 2018;48(3):343–7. 29. Rzany B, Bechara FG, Feise K, Heckmann M, Rapprich S, Worle B. Update of the S1 guidelines on the definition and treatment of primary hyperhidrosis. J Dtsch Dermatol Ges. 2018;16(7):945–52. 30. Pirazzini M, Rossetto O, Eleopra R, Montecucco C.  Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69(2):200–35. 31. Wade R, Llewellyn A, Jones-Diette J, Wright K, Rice S, Layton AM, et  al. Interventional management of hyperhidrosis in secondary care: a systematic review. Br J Dermatol. 2018;179(3):599–608. 32. Shuo L, Ting Y, KeLun W, Rui Z, Rui Z, Hang W.  Efficacy and possible mechanisms of botulinum

B. Haney toxin treatment of oily skin. J Cosmet Dermatol. 2019;18(2):451–7. 33. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. Amsterdam: Elsevier; 2016. 34. Li ZJ, Park SB, Sohn KC, Lee Y, Seo YJ, Kim CD, et al. Regulation of lipid production by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013;72(2):116–22. 35. Hanna E, Xing L, Taylor JH, Bertucci V. Role of botulinum toxin A in improving facial erythema and skin quality. Arch Dermatol Res. 2022;314(8):729–38. https://doi.org/10.1007/s00403-021-02277-0. 36. Schlessinger J, Gilbert E, Cohen JL, Kaufman J. New uses of Abobotulinumtoxin A in aesthetics. Aesthet Surg J. 2017;37(suppl_1):S45–58. 37. Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg. 2002;18(1):35–9. 38. Ziade M, Domergue S, Batifol D, Jreige R, Sebbane M, Goudot P, et al. Use of botulinum toxin type a to improve treatment of facial wounds: a prospective randomised study. J Plast Reconstr Aesthet Surg. 2013;66(2):209–14. 39. Gassner HG, Sherris DA.  Addition of an anesthetic agent to enhance the predictability of the effects of botulinum toxin type a injections: a randomized controlled study. Mayo Clin Proc. 2000;75(7):701–4. 40. Surgery ISoAP. ISAPS International Survey on Aesthetic/Cosmetic Procedures. 2021. 41. Carruthers JC. In: Dover J, editor. Soft tissue augmentation. 3rd ed. Amsterdam: Elsevier; 2013. 42. Bogdan Allemann I, Baumann L.  Hyaluronic acid gel (Juvéderm™) preparations in the treatment of facial wrinkles and folds. Clin Interv Aging. 2008;3(4):629–34. 43. Bray D, Hopkins C, Roberts DN. A review of dermal fillers in facial plastic surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18(4):295–302. 44. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histological study. Dermatol Surg. 1998;24(12):1317–25. 45. Reed RK, Laurent UB, Fraser JR, Laurent TC.  Removal rate of [3H]hyaluronan injected subcutaneously in rabbits. Am J Physiol. 1990;259(2 Pt 2):H532–5. 46. Laurent UB, Dahl LB, Reed RK. Catabolism of hyaluronan in rabbit skin takes place locally, in lymph nodes and liver. Exp Physiol. 1991;76(5):695–703. 47. Tezel A, Fredrickson GH.  The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10(1):35–42. 48. Allergan. Juvederm Voluma XC package insert. Dublin: Allergan; 2013. 49. Galderma. Restylane Lyft with Lidocaine Package Insert. 2018. 50. Flynn TC, Thompson DH, Hyun SH.  Molecular weight analyses and enzymatic degradation profiles of the soft-tissue fillers Belotero balance, Restylane,

6  Facial Rejuvenation/Non-Surgical Procedures and Juvederm ultra. Plast Reconstr Surg. 2013;132(4 Suppl 2):22S–32S. 51. Muti GF. Midface 3D restoration with an innovative high G' filler. J Cosmet Dermatol. 2021;20(Suppl 2):7–11. 52. da Costa A, Biccigo DGZ, de Souza Weimann ET, Mercadante LM, Oliveira PRG, Prebianchi SB, et al. Durability of three different types of hyaluronic acid fillers in skin: are there differences among biphasic, monophasic monodensified, and monophasic polydensified products? Aesthet Surg J. 2017;37(5):573–81. 53. Allergan. Juvederm XC product insert. 2016. 54. Galderma. Restylane Refyne PI. 2016. 55. Galderma. Restylane Defyne PI. 2016. 56. Greene JJ, Sidle DM.  The hyaluronic acid fillers: current understanding of the tissue device Interface. Facial Plast Surg Clin North Am. 2015;23(4):423–32. 57. Ridenour B, Kontis TC.  Injectable calcium hydroxylapatite microspheres (Radiesse). Facial Plast Surg. 2009;25(2):100–5. 58. Lee JC, Lorenc ZP. Synthetic fillers for facial rejuvenation. Clin Plast Surg. 2016;43(3):497–503. 59. Carruthers A, Liebeskind M, Carruthers J, Forster BB.  Radiographic and computed tomographic studies of calcium hydroxylapatite for treatment of HIV-associated facial lipoatrophy and correction of nasolabial folds. Dermatol Surg. 2008;34(Suppl 1):S78–84. 60. Belafsky PC, Postma GN.  Vocal fold augmentation with calcium hydroxylapatite. Otolaryngol Head Neck Surg. 2004;131(4):351–4. 61. Rees CJ, Mouadeb DA, Belafsky PC.  Thyrohyoid vocal fold augmentation with calcium hydroxyapatite. Otolaryngol Head Neck Surg. 2008;138(6):743–6.

63 62. Mevorach RA, Hulbert WC, Rabinowitz R, Kennedy WA, Kogan BA, Kryger JV, et al. Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite. J Urol. 2006;175(1):288–91. 63. Aesthetics M. Radiesse lidocaine injectable implant. Frankfurt am Main: Merz North America; 2016. 64. Engelhard P, Humble G, Mest D. Safety of Sculptra: a review of clinical trial data. J Cosmet Laser Ther. 2005;7(3–4):201–5. 65. Humble G, Mest D.  Soft tissue augmentation using sculptra. Facial Plast Surg. 2004;20(2):157–63. 66. Galderma. Sculptra Aesthetic Prescribing Information. 2016. 67. Schierle CF, Casas LA.  Nonsurgical rejuvenation of the aging face with injectable poly-L-lactic acid for restoration of soft tissue volume. Aesthet Surg J. 2011;31(1):95. 68. Narins RS.  Minimizing adverse events associated with poly-L-lactic acid injection. Dermatol Surg. 2008;34(Suppl 1):S100–4. 69. Attenello NH, Maas CS.  Injectable fillers: review of material and properties. Facial Plast Surg. 2015;31(1):29–34. 70. DeLorenzi C.  Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014;34(4):584–600. 71. Safran T, Gorsky K, Viezel-Mathieu A, Kanevsky J, Gilardino MS.  The role of ultrasound technology in plastic surgery. J Plast Reconstr Aesthet Surg. 2018;71(3):416–24. 72. Cral WG.  Ultrasonography and facial aesthetics. Aesthetic Plast Surg. 2021;46:999.

7

Dermal Fillers for Facial Rejuvenation Arun K. Garg

Abstract

7.1 Introduction

The term facial rejuvenation refers to several different categories of treatments designed to improve the appearance of the face: plastic surgery such as rhinoplasty, blepharoplasty, and rhytidectomy; less invasive procedures such as dermal abrasions and chemical peels; and the growing list of minimally invasive therapies, including laser skin resurfacing, microdermabrasion, neurotoxin injections, and dermal filler injections. Dermal fillers are administered in a very short timeframe and have immediate results. This chapter explores the benefits of using dermal fillers and different methods regarding facial rejuvenation that support aesthetic procedures and correlate with positive results.

In 2019, the American Society of Plastic Surgeons reported that from 2000 to 2018, the number of facelift surgeries declined 9%, while the number of neurotoxin injections increased by a whopping 845%. Similarly, dermal filler treatments have increased 244% since 2006, the first year for which data were collected (Table  7.1) [1]. As these numbers demonstrate, neurotoxins and dermal fillers have radically changed the market for facial rejuvenation procedures in the United States, and this upward trend is expected to continue for at least the next several years. Some of the reasons for this are obvious. Neurotoxins such as Botox Cosmetic (Allergan) and Dysport (Galderma) and dermal fillers can usually be administered in less than an hour; they produce effects that are apparent immediately or within days; and they require little or no downtime. Moreover, these aesthetic enhancements are subtle enough not to attract attention and thus can be undertaken discreetly, which many people appreciate. Indeed, the intent of these procedures is not to make a person look 20 years younger but rather for them to appear more radiant and refreshed at their present age (Fig. 7.1). Unlike surgical procedures, neurotoxin and dermal filler treatments are luxuries that fit many budgets. At an average cost of $397 and $682 per site for neurotoxin and dermal filler (e.g., Juvéderm, Allergan) injections, respectively,

Keywords

Wrinkles · Anesthesia · Fillers · Microneedling · Chin augmentation · Scars · Frown lines · Nasolabial folds · Mental crease

A. K. Garg (*) University of Miami School of Medicine, Miami, FL, USA

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_7

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A. K. Garg

66 Table 7.1  Facial cosmetic procedure trends in the United States since 2000 Procedure Facelift (rhytidectomy) Nose reshaping (rhinoplasty) Eyelid surgery (blepharoplasty) Botulinum toxin type Aa injection Soft tissue fillersb injection

2018 121,531 213,780 206,529 7,437,378 2,676,970

2000 133,856 389,155 327,514 786,911 778,000c

Change −9% −45% −37% +845% +244%

Data reported by the American Society of Plastic Surgeons (https://www.plasticsurgery.org/documents/News/ Statistics/2018/cosmetic-­procedure-­trends-­2018.pdf) a  Includes Botox, Dysport, and Xeomin b  Includes all commercial dermal fillers as well as platelet-rich plasma and acellular dermal matrix c  Number of procedures in 2006, the year data was first reported

all neurotoxin injections and 11% of dermal filler treatments [1].

7.2 Neurotoxins and Dermal Fillers: Understanding the Differences

Fig. 7.1  The effects of neurotoxin and dermal filler treatments are subtle and appear natural, unlike plastic surgery procedures

these treatments are comparable to the cost of a day at the spa. Compare those numbers to the average cost of a simple rhinoplasty ($5350) or dermabrasion ($1250) [1]. The relative affordability of minimally invasive procedures makes them appealing to people at all income levels, including those who likely would never consider seeking surgical treatment to address their age-related aesthetic concerns. The popular stereotype that middleaged women are the ones primarily driving this trend is not at play here. The so-called daddy do-over has been quietly gaining in popularity for several years, and the average age of patients skews younger all the time as more 20and 30-somethings seek dermal filler treatment for acne scars, nose ­recontouring, lip augmentation, and other cosmetic enhancements. In 2018, individuals aged 20–39 made up 18% of

Currently, there are approximately three neurotoxin procedures for every dermal filler procedure performed in the United States (7.4 million vs. 2.6 million) [1]. Botox, the first commercially available neurotoxin, was initially developed and gained FDA approval in 1989 as a therapeutic agent for the treatment of strabismus, an eye muscle disorder. Today, Botox is used to treat neck spasms (cervical dystonia), excessive sweating (hyperhidrosis), and an overactive bladder, among many other conditions. Botox Cosmetic was not FDA approved until 2002, just shortly before the approval of the first hyaluronic acid dermal filler in 2003.

7.3 Dynamic Versus Static Wrinkles Although the aim of these injectable agents is the same—to smooth facial wrinkles—they achieve it through very different mechanisms of action. Cosmetic neurotoxin targets the dynamic lines of expression that result from repetitive facial movement (Fig. 7.2). It is injected directly into the muscles that animate these types of wrinkles, including frown lines, crow’s feet, and forehead creases. The muscles become para-

7  Dermal Fillers for Facial Rejuvenation

Fig. 7.2  Neurotoxins target the dynamic lines and folds of facial expression

Fig. 7.3  Dermal fillers target the static lines and wrinkles that are manifestations of aging on skin

lyzed, and within 2 to 3 days, the lines and wrinkles disappear. These effects last an average of 3 to 4 months. Unlike neurotoxins, dermal fillers target static wrinkles, the ones we develop over time as we age (Fig. 7.3). These static wrinkles are present regardless of facial expression and usually accompany other visible effects of aging, such as hollowed cheeks and eye sockets,

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irregular or blotchy pigmentation, skin laxity, and dryness. These facial manifestations of intrinsic aging are a result of reduced collagen production and slower cell turnover rates. (Their appearance can, however, be accelerated by extrinsic factors such as chronic sun exposure and smoking.) Intrinsic aging is a natural consequence of physiologic changes over time that occur at variable yet genetically determined rates. In some lucky people, these lines, wrinkles, and folds do not make an appearance until they reach 55 or 60  years old, whereas others begin to see them in their late 30 s and 40 s, but for all of us they are an inevitable effect of aging. Nevertheless, our society spends billions of dollars each year on expensive elixirs and procedures in our never-ending quest to prevent and diminish the visible signs of aging on our skin. Moreover, every year, the industry expands with new agents and modalities added to the long list of topical medical products (vitamin A acid, α-hydroxy acids, antioxidants, and moisturizers) and procedures (glycolic acid peels, deep peels, dermabrasion, laser resurfacing, and plastic surgery) already available (Table 7.2). This chapter focuses exclusively on the treatment of a subset of static wrinkles and defects associated with aging: nasolabial folds, marionette lines, mental crease, malar and chin recession, frown lines, and scars. Based on his experience as an educator, the author has found that these conditions are relatively easy for novice practitioners to treat, and the outcomes are generally good. Coincidentally, the areas targeted by these procedures exhibit some of the earliest signs of aging, so patient demand for them is usually high. Step-by-step instructions for treating these areas are preceded by a discussion of anesthesia techniques, a guide to choosing dermal filler products, and a complete how-to on performing facial microneedling. The latter is a simple yet effective procedure that provides all-over skin rejuvenation and perfectly complements the targeted dermal filler injections that are the main subject of this chapter.

A. K. Garg

68 Table 7.2  Costs and total expenditures of the multibillion-dollar industry to combat aginga

Procedure Cosmetic surgical procedures  Cheek implant (malar augmentation)  Chin augmentation (mentoplasty)  Dermabrasion  Ear surgery (otoplasty)  Eyelid surgery (blepharoplasty)  Facelift (rhytidectomy)  Forehead lift  Lip augmentation (other than injectable materials)  Lip reduction  Neck lift  Nose reshaping Cosmetic minimally invasive procedures  Botulinum toxin type A (Botox, Dysport, Xeomin)  Chemical peel  Injection lipolysis (e.g., Kybella [Allergan])  Intense pulsed light (IPL) treatment  Laser hair removal  Laser skin resurfacing    Ablative    Nonablative (Frazxel [Solta Medical], etc.)  Microdermabrasion  Nonsurgical skin tightening (Pelleve [Cynosure], Thermage [Solta Medical], Ultherapy [Ulthera])  Soft tissue fillers    Acellular dermal matrix    Calcium hydroxyapatite (Radiesse [Merz North America])    Fat—face   Hyaluronic acid (e.g., Juvéderm Ultra, Ultra Plus, Voluma, Volbella, and Vollure, Restylane Lyft and Silk [Galderma], Belotero [Merz North America])    Platelet-rich plasma (PRP)    Polylactic acid (Sculptra [Garderma])    Polymethyl-methacrylate microspheres (Bellafill [Suneva Medical]) Total 2018 expenditures

National average surgeon/physician fee

Total expenditure

$3015 $2364 $1249 $3163 $3156 $7655 $3623 $1767 $2009 $5424 $5350

$43,322,535 $38,769,600 $100,790,553 $72,382,092 $651,805,524 $930,319,805 $140,554,285 $54,527,853 $2,147,621 $280,819,182 $1,143,723,000

$397 $669 $1054 $391 $285

$2,952,639,066 $926,114,763 $67,448,622 $264,140,832 $307,084,650

$2071 $1144 $131 $2059

$332,878,043 $495,961,752 $92,933,103 $690,362,110

$2065 $691 $2126 $682

$17,707,375 $157,018,694 $96,435,360 $1,451,925,486

$683 $915 $889

$87,010,102 $111,556,800 $15,614,396 $16,507,440,034

 Data from the American Society of Plastic Surgeons [1]

a

7.4 Anesthesia for Dermal Fillers In facial aesthetics, patients often assess the quality and success of treatment based not on the outcome, but on the process. Pain control is an integral part of the process.

7.4.1 Noninvasive Anesthesia Techniques 7.4.1.1 Cooling Therapy and Vibration There are many different forms of cooling therapy that offer safe, simple, and effective pain

7  Dermal Fillers for Facial Rejuvenation

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Fig. 7.4  Topical ethyl chloride (Gebauer) can be used to numb the injection site prior to injection of dermal fillers

control at the site of the injection. Ice packs, vapocoolants, and contact cooling devices can be used alone or in conjunction with topical anesthetics as a pretreatment for pain. Covered ice can be applied to the skin for about 1 to 2 min to numb injection sites [2, 3]. While this method will only blunt the pain at best, it is safe, inexpensive, and easy. Spraying the injection site with a vapocoolant, such as topical ethyl chloride (Fig. 7.4) or dichlorotetrafluoroethane skin refrigerant, desensitizes topical nerves immediately upon application. This method is less cumbersome than ice packs, fast-acting, and cost-effective. However, the spray should only be used in the cheek and nasolabial folds area, and caution should be exercised for those at risk for reactive hyperpigmentation [2]. Alternatively, contact cooling devices (Fig. 7.5), again applied to the injection site for only 1 to 3  min until the skin is erythematous, not only anesthetize the treatment area, but can also reduce post-treatment ecchymosis and swelling at the site due to the vasoconstrictive effects of the cold. However,

prolonged contact at one site can result in injury to the epidermis. Vibration (Fig. 7.6) has also been shown to be an effective method to minimize the pain of dermal filler injections [2]. The application of a vibration device to an area adjacent to the injection site is thought to reduce pain through stimulation-­induced analgesia – a concept associated with the gate control theory of pain – and by relaxing facial muscles [3, 4]. The vibration is applied concurrently with the injection (Fig. 7.7) or just before it is administered, depending on the model used, and it is completely safe.

7.4.1.2 Topical Anesthesia Topical anesthetics offer the same nerve-­blocking qualities as injectables and can increase patient comfort when used separately or in conjunction with injectable anesthetics [5]. Lidocaine, alone or in combination with another anesthetic, is the most widely used topical anesthetic [6]. Today, many commercially prepared dermal fillers add lidocaine to the product, allowing patients with high resistance to pain the option to receive topi-

A. K. Garg

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cal anesthetics alone in lieu of injectable anesthetics. The effectiveness of a topical anesthetic depends on the depth of skin penetration, the location of the skin surface, the length of exposure time, and the concentration of the ingredients [6]. Table  7.3 lists several properties of different topical anesthetic types [7]. Most topical anesthetics take effect within 15  min of administration of a 0.5-mg dose. Few complications are associated with the use of topical anesthesia (Table  7.4) [6]. For facial Fig. 7.5  A contact dermal cooling device (ArTek Spot, ThermoTek) not only numbs the skin but reduces post-­ dermal filler procedures, topical anesthetic is treatment bruising and swelling as well applied on a relatively small surface area, and therefore the risk of toxicity is minor. The risk of this complication increases when these agents are used on larger surface areas, such as in certain laser treatments [6]. Topical anesthetic procedures begin with the application of alcohol to remove skin oils and to Table 7.3  Properties of topical anesthetics

Fig. 7.6  A vibration anesthesia device (Blaine Labs) achieves its effect through stimulation-induced analgesia and muscle relaxation

Topical anesthetic Lidocaine Lidocaine with prilocaine Tetracaine

Maximum dose 500 mg 60 mg

Onset (min) 25% improvement. The light-only arm of a trial comparing 2 sessions of photodynamic therapy (PDT) with LED 9.3.1.5 Reduction in Pore Size red light therapy (3 treatments per week for Two studies showed significantly reduced pore 4 weeks) applied to forearm skin found that both size after 8 treatments over 4 weeks, an improve- therapies significantly reduced photoaging [21]. ment that lasted at least 3 months. Treatments Dermoscopic evaluation 2 weeks after treatment were conducted with LED or metal halide lamp showed marked improvement in skin appearance sources using a combination of blue and NIR and reduction of photodamage in both groups light, and concomitant glycolic peels and vitamin (although it was more prominent in the PDT C cream; a control group receiving only peels group). and cream saw no change. Ninety percent of patients perceived an improvement in one study

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C. Green and G. Borden

Fig. 9.2  Skin rejuvenation with LLLT, before treatment (left) and after (right) (Photo courtesy of GlobalMed Technologies Co., Glen Ellen, California USA)

9.4 Adverse Effects 9.4.1 Adverse Effects Occurring in Clinical Trials 9.4.1.1 Erythema Erythema is one of the most common side effects of treatment with LLLT, occurring in several studies [18, 19, 23, 27, 28, 37–44]. It has occurred with several types of light sources, using many different devices, at all tested wavelengths including blue, yellow, red, and NIR. Depending on the trial, an incidence from 3 to 40% was reported; however, the effect was most often mild, and all cases of erythema were transient, resolving within hours to a couple of days. 9.4.1.2 Hyperpigmentation Hyperpigmentation is one of the more serious potential side effects of LLLT, occurring with a variety of light sources and different devices, though more often in trials that included blue wavelengths as part of the treatment [27, 42, 45–

54]. The hyperpigmentation was mild and affected from 8 to 80% of subjects within a given study. The duration was moderate, resolving over weeks to months.

9.4.1.3 Ocular Glare, Blurred Vision, and Ocular Floaters One noted six cases of ocular glare appeared with both blue and red light, while a single study subject treated with red light alone reported blurred vision and ocular floaters [33]. Symptoms were more frequent in the group treated with red light, possibly due to the relatively higher lux of the red light. Ocular glare and blurred vision are resolved without treatment, while the participant who experienced floaters dropped out of the study. The floaters resolved over a period of 3 weeks without treatment. Difficulties with the use of eye protection were observed during the initial period of study in the subjects who eventually developed ocular symptoms. Complete eye protection and comprehensive instructions for using LED devices are necessary to mitigate this risk.

9  Low-Level Light Therapy with LEDs

9.4.1.4 Other Adverse Effects Acne trials, generally using blue wavelengths as a component of treatment, have reported several adverse effects not generally seen elsewhere in the literature, including dryness, pruritus, rash, and desquamation, though all were mild, brief, and resolved without intervention [38, 40, 42, 44, 55, 56]. Other trials (using blue and R/NIR wavelengths) have described reactions including pain, burning sensation, edema, and vesiculation, but again all mild (pain 1 out of 10 on visual analog scale) and self-limited [41, 43, 53, 57]. Two individual patients, with telangiectasia and a scar, respectively, reported a temporary increased prominence of those blemishes following treatment [17].

9.4.2 Risks for Preclinical Trials 9.4.2.1 Interactions with Malignancy LLLT has been shown to stimulate growth and progression of cancer cells in vitro [58, 59] and in vivo [60, 61]. The effect may be biphasic and dose-dependent. In an LLLT study on melanoma in mice (660  nm), low-dose treatment reduced tumor size, while high-dose treatment increased the tumor size [60]. LLLT (660  nm, 424  mW/ cm2) every other day for 4 weeks in hamsters has been shown to increase the progression and negatively influence the histology of existing tumors [61]. IR radiation has also been shown to cause a condition called erythema ab igne that leads to an elevated risk of various types of skin cancer. However, the irradiances and cumulative dose in all cases were very high [62]. While the above are theoretical concerns, it should also be noted that R/NIR light is used as part of photodynamic therapy to treat cancers as well, in particular, actinic keratosis and basal cell carcinoma [63]. 9.4.2.2 Photoaging One study demonstrated that, following exposure to a high fluence of IR-A light (360 or 720 J/cm2; 760–1440  nm), intact human skin exhibited

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upregulation of MMP-1 and downregulation of TIMP-1 [64]. Both of these effects would be expected to contribute to collagen and elastin degradation, in contrast to the beneficial effects described above reported by multiple authors using lower doses. In the same report, high fluence IR-A irradiation provoked a decrease in the antioxidant content of the skin. IR radiation was shown to increase the actinic damage caused by UVA in guinea pigs [65]. While the study employed dosages similar to those used clinically (or encountered from natural solar radiation), the epidermis of the epilated guinea pig skin model used is several times thinner than human epidermis. Acute exposure of human skin to an IR fluence over 1300 J/cm2 has been shown to alter the balance between angiogenesis factor VEGF and its inhibitor TSP-2 [66] as well as increase mast cell number and tryptase expression in human skin in vivo [67].

9.4.3 Summary More side effects are associated with blue light treatment than other wavelengths and were reported in disease treatment trials rather than in skin rejuvenation trials. Most studies showing negative effects of near-infrared radiation used artificial light sources far above the solar irradiance threshold, whereas those resulting from treatment with R/NIR wavelengths with dosing commonly used for skin rejuvenation were mostly mild and of a transient, self-resolving nature [62]. With LLLT, more is generally not better. The most frequently reported adverse effects in R/NIR skin rejuvenation trials are erythema (resolving in hours or days), hyperpigmentation (resolving within weeks to months), and ocular symptoms (resolving within weeks and also linked with imperfect participant compliance with eye protection instructions). The potential risks that have appeared in preclinical trials, photoaging and carcinogenesis, arose in the context of much higher doses than are used in human LLLT trials, where they have been absent

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in the literature. Thus, in the event a troublesome adverse event arises during the course of therapy, it is straightforward for the practitioner and patient to simply pause treatment and then reassess.

9.4.4 Treatment Protocols 9.4.4.1 Contraindications and Risk Mitigation Risk mitigation strategies for LLLT are to monitor for developing side effects and discontinue if they arise and to minimize the number of sessions. Eye protection, ideally of the “blackout” variety (as opposed to filtering or dimming), manufactured for use with LLLT should be used. LED sources are much safer than lasers, and momentary accidental eye exposure is unlikely to cause damage. Indeed, many LLLT devices have been commercialized without FDA or other medical regulatory approval because the light output is below a nominal hazard level. Nevertheless, it is imperative to always use proper precautions and follow manufacturers’ safety guidelines. Contraindications to R/NIR LLLT are few and, in general, are relative, not absolute. Many arise more from an abundance of caution rather than direct evidence of harm. Device manufacturers may provide their own guidance and patient screening recommendations. The following is a list of some of the most common clinical scenarios of concern for LLLT therapy and recommended mitigation approaches: 1. Cancer (over tumors or cancerous areas): see preclinical risks above for theoretical concerns in the context of local neoplasms. No convincing human in  vivo studies clearly demonstrate harm; indeed, as noted above, light therapy in combination with topical photosensitizer is used to treat some cancers. Many practitioners and device manufacturers avoid or recommend against LLLT in the setting of cancer due to medicolegal concerns. LLLT treatment should be considered with caution in the presence of malignancy and

only in consultation with the treating oncologist. 2. Direct irradiation of the eyes: most device manufacturers offer or recommend approved eye protection. 3. Photophobia or abnormally high sensitivity to light. 4. Concomitant use of photosensitizing medication. 5. Epilepsy, porphyria, and lupus erythematosus are listed as absolute contraindications for Omnilux devices. 6. Pregnancy: no studies showing harm or safety exist. Many practitioners and device manufacturers avoid or recommend against LLLT during pregnancy due to medicolegal concerns. Consider only in consultation with the patient’s obstetrician. 7. Avoid direct irradiation over the thyroid gland: this is another theoretical concern, as yet unsubstantiated by human studies or clinical reports. One study reported a potent restorative effect to T3 following LLLT in Hashimoto thyroiditis; the possibility of unwanted changes in euthyroid individuals therefore warrants some caution [68]. Simply covering the thyroid area during treatment is a straightforward mitigation. 8. Individuals with very dark skin, or with dark tattoos or scars: dark pigments absorb more light than fair skin. Reducing exposure time or intensity accordingly, with heightened monitoring, is a reasonable approach. Similar flexibility may be applied to irradiation of scarred tissue. 9. Symptoms of unknown cause: common sense dictates avoiding adding non-mandatory variables such as LLLT in the presence of a pre-existing clinical mystery.

9.4.5 Dosing LLLT is characterized by a biphasic dose-­ response in which lower doses are often more beneficial than higher ones [69]. Too low a dose can result in reduced effectiveness and too high a dose can lead to tissue damage. Many studies

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include negative results that could stem from inappropriate dosing rather than a defect in the treatment itself. The dose imparted during a particular LLLT session corresponds to the fluence, the light energy incident upon tissue per unit area. Skin reflects just a few percent of incident photons in the visible and infrared bands [70]. The majority is therefore ultimately absorbed within tissue, often after scattering. Consequently, the absorbed dose is well approximated by the incident dose, calculated by taking the product of the incident power density and the treatment time. While this is conceptually straightforward, there are important considerations, chiefly safety, patient convenience, and device geometry and specifications. LEDs are manufactured such that their output subtends a specified solid angle, forming a cone. In LLLT devices constructed with LED arrays, the output cones of individual LED components overlap, or even converge, at a particular distance according to the device geometry. Thus, intensity does not necessarily strictly decrease with distance, and it is possible for a more distant target to receive more intense illumination than a closer one. Proper relative positioning of source and target according to manufacturers’ information is therefore imperative to ensure optimal beam intensity at the target and achieve desired effects. Power delivery to tissue as a function of depth is another consideration. For R/NIR wavelengths, subsurface scattering and tissue structure and composition results in potentially greater energy deposition per unit volume within tissue than at the surface; peak energy deposition depth varies with wavelength, skin type, and condition and is challenging to measure empirically. As with penetration depth, peak energy deposition depth increases with wavelength within the commonly used therapeutic range [1, 71–73]. For LLLT to remain safely athermal, the power density of the incident beam must remain low relative to the dissipative capacity of the target tissue. On the other hand, clinical feasibility demands that treatment sessions be manageably brief. Fortunately, effective fluences described in

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the literature correspond to treatment times under half an hour with incident power density in the 100  mW/cm2range, which perhaps not coincidentally is roughly equivalent to the incident power density of sunlight at noon on a clear summer day in mid-latitudes.

9.4.6 State of Target Cells and Tissues Compromised cells have been shown to respond much more to LLLT than normal cells do [1]. Therefore, the magnitude of PBM depends on the condition of the cell at the moment of irradiation. For example, light stimulates cell proliferation only if cells are growing poorly at the time [74].

9.4.7 Pulsed Wave Vs. Continuous Wave Mode Theoretically, pulsed bursts of light may travel deeper into tissues than continuous-wave radiation because the first part of a powerful pulse may contain enough photons to briefly saturate all chromophores in the upper tissue layers, leaving the remainder of the pulse to pass further into the tissue. However, the influence of continuous wave versus pulsed wave mode as well as precise pulsing parameters (i.e., duration, interval, pulse per train, pulse train interval) on cellular response has not been fully studied, and comparative studies have shown conflicting results [74]. Guidance on this variable must therefore await future research.

9.4.8 Treatment Frequency and Duration While the optimal frequency and number of treatment sessions have not been rigorously determined, some practical rules of thumb can be reasonably formulated from the literature. Repeated exposure to large doses of incident IR power densities sufficient to cause heating reproduces a pattern of connective tissue damage

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similar to photoaging [69, 75]. Even with thermal power densities and low fluence dosing, it is advisable to minimize treatment sessions to avoid any possible photoaging or theoretical risk of carcinogenesis. However, many benefits reported in the literature peaked only after several weeks into the treatment regimen, suggesting that repeated sessions are necessary for maximum benefit. While the highest number of treatments described among the trials cited herein was 60, most studies utilized a total of 8–12 sessions and reported few adverse effects; this represents a sensible treatment guideline.

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ï 2_5 cm distance. ï IR (830  nm, 55  mW/cm2, 66  J/cm2 per treatment). ï Red (633  nm, 105  mW/cm2, 126  J/cm2 per treatment).

9.4.9.2 Maintenance Therapy Monthly maintenance sessions (one with red light, one with NIR) are recommended after completing an initial series.

9.4.10 Evaluation of Treatment

Session Protocol ï Cleanse and exfoliate the skin using a choice of polyethylene-based scrub, microdermabrasion or a mild peel with AHAs and BHAs.Ï 9 treatments over a 5-week period (IR 6 times + red 3 times). ï 20 min per treatment. ï 2–5 cm distance. ï IR (830 nm, 55 mW/cm2, 60 J/cm2) on days 1, 3, 5, 15, 22, and 29. ï Red (633  nm, 105  mW/cm2, 126  J/cm2) on days 8, 10, 12.

9.4.10.1 Ultrasound Wunsch and Matuschka used a DermaLab Combo ultrasound unit (Cortex Technology, Hadsund, Denmark) to generate a collagen intensity score, effectively measuring intradermal collagen density noninvasively [17]. This appears to be an under-utilized method of obtaining an objective measure of treatment response readily available to the clinician. In this imaging modality, a 20 MHz, rotating single element probe operating in B mode is used to scan to a depth of approximately 3 mm and instantly assess collagen level and dermal thickness. Besides the study cited above, other authors have monitored response to various treatments by measuring dermal collagen intensity with the DermaLab system [76, 77]. Beyond the specific collagen intensity score offered by the DermaLab system, there are other parameters and observations that may be gleaned from any suitable (≥20  MHz probe recommended) ultrasound platform [78]. For example, collagen loss and matrix degradation typical of skin aging in photoexposed regions is readily visualized by high-frequency ultrasound as a subepidermal hypoechogenic band [79, 80].

Session Protocol ï Cleanse and exfoliate the skin using a choice of; polyethylene-based scrub, microdermabrasion or a mild peel with AHAs and BHAs. ï 8 alternating treatments over a 4-week period (IR 4 times + red 4 times). ï 20 min per treatment.ï Allow at least 48 h rest-time between treatments.

9.4.10.2 Profilometry Profilometry, the study of surface features, is another modality available to the clinician to potentially guide and evaluate treatment. Historically as applied to the skin, profilometry involved first making a negative mold of the region of interest, typically of low viscosity

9.4.9 Sample Treatment Protocols 9.4.9.1 Summary There are relatively few trials comparing different treatment protocols head-to-head, with Lee et al. [15] being perhaps the best exemplar. The protocols below are adapted from trials using Omnilux devices and the manufacturer’s recommendations. They could be adapted for use with other devices emitting similar wavelengths, with care taken to reproduce the described fluence and dose by varying the distance between patient and device and, if necessary, treatment time.

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silicone; variations in the thickness of this impression could then be measured by optical transmission to generate objective data reflecting surface characteristics [81]. Current state of the art devices employ contactless fringe projection to map multiple parameters over large areas, such as the entire face, in a single acquisition [80]. To some extent, roughness parameters derived from profilometry correlate with ultrasonographic dermal measurements [82], but overall, profilometry and ultrasound yield complementary information regarding surface and subsurface features, respectively.

9.5 Conclusion Low level light therapy, using LED-based devices working in the red and near-infrared ranges, is a promising treatment modality for aesthetic medicine applications. It represents a relatively safe, convenient, and economically accessible approach with many potential benefits to the patient. While imaging has long been part of LLLT research, it is increasingly possible, and indeed recommended, to employ imaging as part of clinical practice to inform and monitor therapy. A basic, but not to be overlooked method is to take a careful series of pre- and post-treatment photographs under reproducible lighting conditions; this is a method accessible to most practitioners. As mentioned above, appropriate investments in equipment allow measurements by ultrasound and profilometry. Future directions for research in LLLT may beneficially include standard reporting of treatment parameters such as power density, treatment area, and distance to light source. The field would also be aided by more frequent reporting of standard clinical scales as well as further inclusion of objective measures such as collagen density and profilometric data. Finally, different protocols, for example, the two included in this chapter, will ideally be tested head-to-head in future work, in order to better establish the optimum course of therapy.

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124 56. Kawada A, Aragane Y, Kameyama H, Sangen Y, Tezuka T.  Acne phototherapy with a high-intensity, enhanced, narrow-band, blue light source: an open study and in  vitro investigation. J Dermatol Sci. 2002;30(2):129–35. 57. Reinhold U, Dirschka T, Ostendorf R, Aschoff R, Berking C, Philipp-Dormston WG, et al. A randomized, double-blind, phase III, multicentre study to evaluate the safety and efficacy of BF -200 ALA (Ameluz®) vs. placebo in the field-directed treatment of mild-to-moderate actinic keratosis with photodynamic therapy (PDT) when using the BF -Rhodo LED ® lamp. Br J Dermatol. 2016;175(4):696–705. https:// doi.org/10.1111/bjd.14498. 58. Sroka R, Schaffer M, Fuchs C, Pongratz T, Schrader-­ Reichard U, Busch M, et  al. Effects on the mitosis of normal and tumor cells induced by light treatment of different wavelengths. Lasers Surg Med. 1999;25(3):263–71. 59. Sperandio FF, Giudice FS, Corrêa L, Pinto DS, Hamblin MR, de Sousa SCOM.  Low-level laser therapy can produce increased aggressiveness of dysplastic and oral cancer cell lines by modulation of Akt/mTOR signaling pathway. J Biophotonics. 2013;6(10):839. https://doi.org/10.1002/ jbio.201300015. 60. Frigo L, Luppi JSS, Favero GM, Maria DA, Penna SC, Bjordal JM, et  al. The effect of low-level laser irradiation (in-ga-Al-AsP—660 nm) on melanoma in vitro and in vivo. BMC Cancer. 2009;9:404. 61. De Monteiro CJS, Pinheiro ALB, De Oliveira SCPS, Aciole GTS, Sousa JAC, Cangussú MCT, et  al. Influence of laser phototherapy (λ660 nm) on the outcome of oral chemical carcinogenesis on the hamster cheek pouch model: histological study. Photomed Laser Surg. 2011;29(11):741–5. https:// doi.org/10.1089/pho.2010.2896. 62. Barolet D, Christiaens F, Hamblin MR.  Infrared and skin: friend or foe. J Photochem Photobiol B. 2016;155:78–85. 63. Ericson MB, Wennberg A-M, Larkö O.  Review of photodynamic therapy in actinic keratosis and basal cell carcinoma. Ther Clin Risk Manag. 2008;4(1):1– 9. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2503644/ 64. Schroeder P, Lademann J, Darvin ME, Stege H, Marks C, Bruhnke S, et al. Infrared radiation-induced matrix metalloproteinase in human skin: implications for protection. J Invest Dermatol. 2008;128(10):2491–7. 65. Kligman LH.  Intensification of ultraviolet-induced dermal damage by infrared radiation. Arch Dermatol Res. 1982;272(3–4):229–38. 66. Kim M-S, Kim YK, Cho KH, Chung JH.  Infrared exposure induces an angiogenic switch in human skin that is partially mediated by heat: IR induces angiogenesis in human skin in  vivo. Br J Dermatol. 2006;155(6):1131–8. https://doi. org/10.1111/j.1365-­2133.2006.07510.x. 67. Kim M-S, Kim YK, Lee DH, Seo JE, Cho KH, Eun HC, et al. Acute exposure of human skin to ultravio-

C. Green and G. Borden let or infrared radiation or heat stimuli increases mast cell numbers and tryptase expression in human skin in vivo. Br J Dermatol. 2009;160(2):393–402. https:// doi.org/10.1111/j.1365-­2133.2008.08838.x. 68. Ercetin C, Sahbaz NA, Acar S, Tutal F, Erbil Y. Impact of photobiomodulation on T3/T4 ratio and quality of life in hashimoto thyroiditis. Photobiomodul Photomed Laser Surg. 2020;38(7):409–12. https:// doi.org/10.1089/photob.2019.4740. 69. Chung H, Dai T, Sharma SK, Huang Y-Y, Carroll JD, Hamblin MR.  The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng. 2012;40(2):516–33. 70. Lister T, Wright PA, Chappell PH. Optical properties of human skin. J Biomed Opt. 2012;17(9):–90901. 71. Douplik A, Saiko G, Schelkanova I, Tuchin VV. The response of tissue to laser light. In: Jelínková H, editor. Lasers for medical applications. Sawston: Woodhead Publishing; 2013. p.  47–109. (Woodhead Publishing Series in Electronic and Optical Materials). https://www.sciencedirect.com/science/article/pii/ B9780857092373500035. 72. Milanic M, Majaron B. Energy deposition profile in human skin upon irradiation with a 1,342 nm Nd:YAP laser. Lasers Surg Med. 2013;28:45. 73. Shimojo Y, Nishimura T, Hazama H, Ozawa T, Awazu K.  Measurement of absorption and reduced scattering coefficients in Asian human epidermis, dermis, and subcutaneous fat tissues in the 400- to 1100-nm wavelength range for optical penetration depth and energy deposition analysis. J Biomed Opt. 2020;25(4):045002. https://www.spiedigitallibrary.org/journals/journal-­o f-­b iomedical-­o ptics/ volume-­2 5/issue-­4 /045002/Measurement-­o f-­ absorption-­and-­reduced-­scattering-­coefficients-­in-­ Asian-­human/10.1117/1.JBO.25.4.045002.short. 74. Barolet D. Light-emitting diodes (LEDs) in dermatology. Semin Cutan Med Surg. 2008;27(4):227–38. 75. Cho S, Shin MH, Kim YK, Seo J-E, Lee YM, Park C-H, et  al. Effects of infrared radiation and heat on human skin aging in vivo. J Investig Dermatol Symp Proc. 2009;14(1):15–9. 76. Borumand M, Sibilla S.  Daily consumption of the collagen supplement pure gold collagen® reduces visible signs of aging. Clin Interv Aging. 2014;9:1747– 58. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4206255/. 77. Hsu T-F, Su Z-R, Hsieh Y-H, Wang M-F, Oe M, Matsuoka R, et al. Oral hyaluronan relieves wrinkles and improves dry skin: a 12-week double-blinded, placebo-controlled study. Nutrients. 2021;13(7):2220. https://www.mdpi.com/2072-­6643/13/7/2220. 78. Vergilio MM, Vasques LI, Leonardi GR.  Characterization of skin aging through high-­ frequency ultrasound imaging as a technique for evaluating the effectiveness of anti-aging products and procedures: a review. Skin Res Technol. 2021;27(5):966–73. https://doi.org/10.1111/ srt.13033. 79. Crisan D, Lupsor M, Boca A, Crisan M, Badea R.  Ultrasonographic assessment of skin structure

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Tips and Tricks for Intense Pulse Light Treatment

10

Lucian Fodor and Sergiu Samuila

Abstract

IPL represents a technology that uses electromagnetic radiation energy with a wavelength situated in the visible light spectrum. With the use of thermal relaxation time (TRT), nonspecific injury of unaffected tissue is induced. This chapter explores the benefits of IPL technology, noting energy sufficiency and the rapid recovery time of patients. Keywords

IPL · TRT · Chromophores · Photorejuvenation · Lesions · Scars · Hair removal · Laser · Hyperpigmentation · Body dysmorphic disorder

10.1 Introduction The effects of the IPL therapy are based on the light-tissue interaction. The light that reaches the skin is absorbed, reflected, scattered, or transmitted into the surrounding structures L. Fodor (*) Plastic Surgery, Interservisan, MedÁrt Clinic, Cluj Napoca, Romania e-mail: [email protected] S. Samuila Plastic Surgery, Emergency District Hospital, Cluj-Napoca, Romania

(Fig. 10.1a–d). Each of these processes depends on the patient’s characteristics or technical settings. Heating effect due to light absorption is responsible for various changes at the molecular level, resulting in coagulation and denaturation of different protein structures of the target tissues [1–3]. Selective photo thermolysis represents the principle of IPL function [4]. Chromophores are the structural components of the tissues that absorb the light photons. They are situated at different depths in the skin and have different wavelengths of absorption (Fig.  10.2). The main chromophores present at the skin level are melanin, hemoglobin, water, and foreign pigmented tattoos [5] melanin, which is located mainly at the epidermis level, and hemoglobin, found in the vascular network of the dermis, are the principal targets of pulsed light treatment [6, 7] (Fig. 10.3a, b). In order to obtain selective photothermolysis on a target tissue and avoid thermal injury on the surrounding tissues, a matching of wavelength and duration of pulse must be obtained. Thermal relaxation time (TRT), which represents the time needed to cool a small tissue, is a variable that influences the non-specific thermal injury of unaffected tissue. TRT is proportional to the square of the size [6]. When pulse duration is longer than TRT, complications secondary to thermal injury of the healthy tissue can occur [4].

© Springer Nature Switzerland AG 2023 R. L. Bard (ed.), Image-Guided Aesthetic Treatments, https://doi.org/10.1007/978-3-031-36266-8_10

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L. Fodor and S. Samuila

128

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c

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Fig. 10.1 (a) Scattering effect (photos from Fodor and Ullmann second edition). (b) Reflection of the light (photos from Fodor and Ullmann second edition). (c) 100,000

Er: YAG

10,000

Melanin

1,000 Absorption Coefficient (per centimeter)

Fig. 10.2 Light absorption for different chromophores. (Photos from Fodor and Ullmann second edition)

Light transmission (photos from Fodor and Ullmann second edition). (d) Light absorption. (Photos from Fodor and Ullmann second edition)

100

Water

Hemoglobin

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Oxyhemoglobin

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Fig. 10.3 (a) Café-au lait in a young person. The melanin is the main chromophore. (b) Good result after two IPL treatments. (Photos from Fodor and Ullmann second edition)

10  Tips and Tricks for Intense Pulse Light Treatment

a

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b

Fig. 10.4 (a) PWS—adult type over the nose. The chromophore is the hemoglobin. (b) Good result after ten IPL treatments. (Photos from Fodor and Ullmann second edition)

10.2 Indications ILP devices utilize a light source to emit polychromatic light with wavelengths between 420 and 1200  nm and have the possibility to adjust numerous parameters of the devices, e.g., fluence, pulse duration and frequency, and filter type. This versatility allows for the treatment of a wide range of skin conditions, including telangiectasias, facial wrinkles, photorejuvenation, hyperpigmentation, ephelides, lentigines, melasma, rosacea, acne, poikiloderma of Civatte, port wine stains (PWS) (Fig. 10.4a, b), hemangiomas, superficial leg veins, and scars [8].

10.3 Vascular Lesions In cases of vascular lesions, the target tissues are the blood vessels located in the dermal plexus of the skin. Using specific filters, the shorter and superficial penetrating wavelengths can be eliminated, and longer wavelengths can be delivered to the specific chromophores existing in the vascular lesions, e.g., oxyhemoglobin and deoxyhemoglobin. Secondary to light absorption by these chromophores, selective vascular destruction can be obtained with limited non-­specific melanin absorption with unwanted results [9, 10] (Fig. 10.5a, b).

Chronic venous insufficiency is a condition with a height prevalence reported in Western countries of 17–40% [11]. Telangiectasias, dilated superficial small veins (